Lecture Notes On Psychiatry

Study Notes in Psychiatry (2008)
Dr. Roger Ho
Tab e o! "ontent
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Study Notes in Psychiatry (For MBBS III to V)
Dr. Roger Ho MBBS (HK), DPM( Ireland), MMed (Psych) Department of Psychological edicine! N"S #mail$ pcmrhcm%nus.edu.sg
Dr. Roger Ho
"h. # Introduction "h.$ Signs % sy&'to&s (cute &anage&ent "h. ) Schi*o'hrenia "h. + De usiona disorder "h. - Bi'o ar disorder "h. , De'ressi/e disorder "h. . 1bsessi/e co&'u si/e disorder "h. 3 (n4iety5 Panic5 Phobia "h. 0 Post trau&atic stress disorder5 (cute stress5 grie! "h. #2 ( coho is& "h. ## Drug De'endence "h. #$ 1 d age 'sychiatry "h. #) "onsu tation 6iaison Psychiatry "h. #+ Perinata Psychiatry "h. #- 7ating disorder and i&'u se contro disorders "h. #, Suicide and DSH "h. #. Persona ity Disorder "h. #3 Psychiatric e&ergencies "h. #0 S ee' disorders "h. $2 "hi d Psychiatry "h. $# 6earning disabi ity "h. $$ 6ega as'ect "h. $) Psychothera'y
"ha'ter # Introduction
$ $ ) , . 0 #2 ## #$ #) #+ ##, #3 #0 $# $$ $) $+ $$3 $0 )2
&he purpose of 'riting this set of notes is to pro(ide a concise summary of psychiatry and to help medical students to ha(e rapid re(ie' for e)amination. "h. $ De!initions o! signs and sy&'to&s The MCQ exam often confuses you !th the follo !n" terms (#e$!, %&&')(
7cho a ia Repetition *y the patient of the inter(ie'er+s 8ords or 'hrases Stereoty'y Regular! repetiti(e non goal-directed mo(ement ('ur'ose ess) 9a4y ! e4ibi ity Patient+s lim* can *e placed in an a'/'ard posture and remain fi)ed in position for long time des'ite as:ing to re a4; occurs in Schi0ophrenia (S1) "ata e'sy otor symptom of schi0ophrenia! same as 'a)y fle)i*ility
7cho'ra4ia ,mitation *y the patient of the inter(ie'er+s &o/e&ents. Manneris& .*normal! repetiti(e goal-directed mo(ement (o! so&e !unctiona signi!icance) Mit&achen Patient+s *ody can *e placed in any posture; 8hen re a4ed5 'atient returns to resting 'osition "ata' e4y Symptom of narco e'sy in 'hich there is sudden loss of muscle tone leading to collapse! occurs in emotional state. <egenha ten (o''osition) &he patient 'ill oppose attempts at passi(e mo(ement 'ith a force e2ual to that *eing applied. Negati/is& #)treme form of gegenha ten5 moti(eless resistance to suggestion3 attempts at mo(ement. Preser/ation &he senseless re'etition of a pre(iously re2uested &o/e&ent5 e(en
(uto&atic obedience Patient does 'hate(er the inter(ie'er as/s of him irrespecti(e of the conse2uences Mitgehen .n e)treme form of &it&achen in 'hich patient 'ill mo(e in any direction 'ith (ery slight pressure (&bitendence &he patient *eings to ma/e a mo(ement *ut *efore completing it! starts
Dr. Roger Ho
the o''osite &o/e&ent Neo ogis&s &he patient uses 8ords or 'hrases in/ented *y himself 1bsessions Recurrent! persistent thoughts! impulses! images that the patient regards as absurd and alien 'hile recognising as the product of his o'n mind. .ttempts are made to resist or ignore them Verbigeration (8ord sa d) Disruption of *oth the connection *et'een topics and finer grammatical structure of speech 6ccurs in S1 6ossening o! associations 6oss o! the nor&a structure of thin/ing. uddled and illogical conser(ation that cannot *e clarified 6ccurs in S1
after the stimulus is 'ithdra'n Metony&s "se of ordinary 'ords in unusal 'ays De usions . !a se be ie! 'ith the follo'ing characteristics firmly held despite e(idence to the contrary4 out o! :ee'ing 'ith the person+s education 5 cultural *ac/ground! content often *i0arre Vorbeireden (ta :ing 'ast 'oint) &he patient seems al'ays a*out to get near to the matter in hand *ut ne/er =uite reaches it. 6ccurs in S1 F ight o! ideas Patient+s thoughts and conser(ations mo(e =uic: y !rom one topic to another! the lin/s *et'een these ra'id y changing to'ics are understanda*le .ssociated 'ith rhyming! punning 5 clang associations. Derea isation . change in self a'areness such that the en/iron&ent feels unreal Bi'o ar II Hypomania Mood #motional state o(er a longer period 7uthy&ia . normal mood state Neither depressed or mania
).# Ty'es o! schi*o'hrenia > Paranoid schi*o'hrenia$ prominent 'ell 7 systematised persecutory delusions or hallucinations. ore common 'ith increasing age. > "atatonic schi*o'hrenia? 9R7N"H7S 8 7 8a)y fle)i*ility4 catalepsy R 7 Rigidity # 7 #chopra)ia! echopra)ia N 7 Negati(ism 9 7 9atalepsy H 7 High le(el of motor acti(ity # 7 #cholalia S - Stupor 6ther features$ automatic o*edience! stereotypy4 am*itendence! mannerism4 mitmachem4 mitgehen. ).$ 7'ide&io ogy Median age o! onset? Ma e Fe&a e 2: years 2; years (earlier onset) (later onset) Se4$ e2ually *et'een men 5 'omen Socia c ass$ increased pre(alence in lo'er social class Season o! birth? increased incidence in 'inter months Pre/a ence rate? <= of general population Incidence? <>3<00 000 ).) (etio ogy > <enetics? Herita*ility$ ;0-80= > Fa&i y studies sho' the pre(alence rates of schi0ophrenia in relati(es as follo's$ Re ationshi' to S@ Pre/a ence rate Parent of a S1 >= Si*ling of a S13 D1 &'in <0= 9hild of one S1 parents <?= 9hild of t'o S1 parents ?>= ono0ygotic t'ins of S1 ?>= Bioche&ica theories? #)) Do'a&ine o/er>acti/ity? high le(el of dopamine 'ithin &eso i&bic cortica bund e. (eg amphetamine increase dopamine release4 Haloperidol reduces its release). $) Serotonergic o/eracti/ity? @SD! inc >H&! leads to hallucination! clo0apine has serotonergic antagonism. )) A# B adrenergic o/eracti/ity.
De'ersona isation . change in self a'areness such that 'erson feels unreal Bi'o ar I ania (!!ect #motional state at a moment 7u'horia Sustained and un'arranted cheerfulness "ha'ter )
Schi*o'hrenia
Dr. Roger Ho
+) < uta&inergic hy'oacti/ity$ /etamine! N D. antagonist! induce S1 symptoms -) <(B( hy'oacti/ity 'hich leas to o(eracti(ity of dopamine! serotonin! noradrenaline. 7n/iron&enta !actors? - 9omplications of pregnancy! deli(ery. - aternal influen0a in pregnancy! 'inter *irths > Non 7 localising soft signs in childhood$ astereognosis! dysgraphaesthesia! gait a*normalities! clumsiness. - Distur*ed childhood *eha(iour - Degree of ur*anisation at *irth ).+ Pathogenesis ((''endi4 )aC)b) #) Neurode/e o'&enta hy'othesis $) Thic:ening o! cor'us ca osu& )) Ventricu ar en arge&ent ).- " inica !eatures (a''endi4 )c) > First ran: sy&'to&sC Positi/e > Negati/e sy&'to&s > Neo ogis&s5 Metony&s )., Diagnosis (DSM B IV) - .t least 2 of the follo'ing for at least < month$ (.A9D B P@.N& C) - Social 3 occupational dysfunction - Post 7 schi0ophrenic depression is common ).. Di!!erentia diagnosis? Doung adu ts 1 der 'atients - Drug induced - .cute organic psychosis syndrome$ - &emporal lo*e encephalitis epilepsy - Dementia - Diffuse *rain disease 1ther DDE$ psychotic depression! paranoid personality disorder ).3 P7 and In/estigation - Dull neurological e)amination$ gait and motor - 9ogniti(e e)amination$ S# - Alood$ DA9! @D&! RD&! &D&! glucose. - 9& or R, *rain - "rine drug screen - ##E if suspects of &@#
).0 "on/entiona anti'sychotics Ty'ica anti'sychotics? -"h or'ro&a*ine$ more antiadrenergic 5 antihistaminergic (<00 7 ?00mg daily) - Ha o'erido $ more #PS# (> 7 <0mg daily) - Tri! u'era*ine$ more #PS#$ > 7 <0mg daily Aloc/ mesolim*ic .ntipsychotic action cortical *undle Al/ Nigrostriatal #)trapyramidal effects Al/ &u*eroEalactorrhoea infundi*ular acti(ity Side e!!ects o! ty'ica anti'sychotics? #) 74tra'yra&ida side e!!ects (7PS7)? -.cute dystonia$ treated *y , antimuscarinic (congentin 2mg) - ./athisia$ restlessness$ treated *y propanolol <0mg &DS - Pseudopar/insonism$ oral antimuscarinic$ *enhe)ol 2mg AD - &ardi(e dys/inesia 2) Hy'er'ro actinae&ia :) (ntiadrenergic? sedation! postural hypotension! failure of eFaculation ?) (nticho inergic? dry mouth! urinary retention! constipation >) (ntihista&inergic? sedation ;) (ntiserotonergic? depression More on Tardi/e dys:inesia (TD) > .fter chronic use of antipsychotic - Due to upregulation of postsynaptic Dopamine receptors in Basa <ang ia - ore common in !e&a e - History of chronic *rain disease$ ris/ factor -slo' 'rithing mo(ement (athetosis) -Sudden in(oluntary mo(ements - 6ral lingual region (chorea) - &emporary raise the dose may gi(e immediate relief4 try to maintain &ini&u& e!!ecti/e dose in long run - 9hange to aty'ica anti'sychotics - Vita&in 7 may pre(ent deterioration - .nticholinergic 'ill 'orsen &D. "on/entiona de'ot anti'sychotics , Dlupenti)ol 20 7 ?0mg ? 'ee/ly (Dluan)ol) 6ther odecate! 9lopi)ol - @ong acting depot inFection for non compliant patients. - &o gi(e a test dose to ensure no idiosyncratic effects
Manage&ent?
Dr. Roger Ho
- High incidence of #PS# ).#2 (ty'ica anti'sychotics Ris'eridone? #>$&g 1N (F#C&g) Higher affinity of D2 in mesolimi*ic and less in nitrostriatal4 higher affinity for >H&2 and G< receptors. Side effects$ - #PS# (if high dose li/e ?mg daily) - #le(ation of prolactin (strongest among atypicals) - .ntiadrenergic side effects 1ther 're'arations o! ris'eridone? P1 Ris'erda =uic: et? 2uic/ly dissol(e in mouth P1 Ris'erda so ution? <mg3ml HI03 *ottle. IM Ris'erda consta 7 only atypical depots Start 'ith , 2>mg! increase to :I.>mg e(ery 2 'ee/s 1 an*a'ine? -> #2&g 1N (F#C&g) oderate for D24 High affinity for >H&2 and muscarinic receptors Side effects$ - 9eight gain and increase a''etite - Sedation - .ntiadrenergic side effects - Prolongation of J& inter(al on #9E - Hyperprolactinemia (transient) Guetia'ine? #22 B 322&g dai y (F$C#22&g) 8ea/ for D2! High affinity for >H&2 and G< Side effects$ - (ntiadrenergic side e!!ects li/e postural hypotension - Pro ong GT inter/a - .lmost no #PS# (same as place*o) - No K in prolactin (same as place*o) Su 'iride $22&g B +22&g 1N (IMH) > @o' dose$ *loc/ D: and D?$ negati(e symptoms - High dose$ *loc/ D2 and D<$ positi(e symptoms - De'er #PS#! less sedation! cause galactorrhoea. " o*a'ine? more acti(e at D?! >H&2! G< 5 muscarinic receptors - for treatment resistant S1.(failure of 2 antipsychotics 'ith ade2uate dose)
Side effects include$ - @ife threatening agranulocytosis 2-:=4 needs regular DA9 under clo0aril patient monitoring programme (, H) - Hypersali(ation - .nticholinergic and antiadrenergic. - De'er #PS# ).## Psycho ogica treat&ent? >Psychoeducation can pre(ent relapse *y enhancing insight -"ogniti/e Beha/ioura thera'y ("BT) to challenge delusions. -Socia s:i training$ impro(e relationship - Beha/ioura $ positi(e reinforcement of desira*le *eha(iour. Fa&i y thera'y? to reduce e4'ressed e&otion (77). (High 77 inc ude hostility! o(er-in(ol(ement! critical comments from family4 hence reduce relapse rate) ).#$ 1ther treat&ents? - Rehabi itation (IMH) to enhance self care! compliance and insight. - 7"T is for catatonic schi0ophrenia Indications !or Hos'ita ad&ission? Suicide 3 (iolent Se(ere psychosis Se(ere depression 9atatonic schi0ophrenia Non 7 compliance Dailure of outpatient treatment ).#) Prognosis Ru es o! =uarters $-H $-H 9omplete Eood Remission reco(ery
$-H Partial reco(ery
$-H Do'nhill course
<ood 'rognosis? ar/ed mood distur*ance - Damily history of affecti(e disorder - Demale se) - @i(ing in a de(eloping country - .cute onset - Eood premor*id adFustment Poor 'rognosis? adolescence or early onset! enlarged (entricles. "auses o! re a'se? #) Iatrogenic re a'se? reduction of dose *y doctor
Dr. Roger Ho
2) Non co&' iance :) High e4'ressed e&otion ).#+ "o&' ications o! S@ > 9ater into4ication in chronic schi0ophrenia! leading to hypanatraemia. > Suicide is the most common cause of death of S1! <0-:8= of all deaths of S1. > S@ and /io ence? contro(ersial$ senior psychiatrists say no *ut recent findings support the association. ,n e)am! safer to say no association. Schi*oa!!ecti/e disorder ,t is a disorder in 'hich the symptoms of schi0ophrenia and affecti(e disorder are present in appro)imately in e2ual proportion. ,9D <0 re2uires *oth psychotic and mood episode are simultaneously present and e2ual prominent. Treat&ent? .ntipsychotics B antidepressant or mood sta*ili0er. Schi*oty'a 'ersona ity disorder - &here is familial relationship *et'een schi0otypal personality disorder 5 schi0ophrenia " inica !eatures? IF1 RID7 " 7 unusual perception$ eg telepathy D 7 Driendless 6 7 6dd *elief and odd speech R 7 Reluctant to engage , 7 ,dea of reference D 7 Dou*tful of others # 7 #ccentric *eha(iour - Poor prognosis$ >0= de(elop schi0ophrenia Schi*oid 'ersona ity disorder 7 introspecti(e+ prone to engaged in an inner 'orld of fantasy rather than ta/e action4 lac/ of emotional 'armth and rapport4 self sufficient and detached4 aloof and humourless4 incapa*le of e)pressing tenderness or affection4 shy4 often eccentric4 insensiti(e4 ill 7 at 7 ease in company
"h.+ De usiona Disorder (14!ord Handboo:5 $22+) +.# Ty'es o! de usiona disorder (DSM IV) > 7roto&anic (de " era&bau t syndro&e)? ,mportant person li/e P is secretly in lo(e 'ith them4 usually female4 ma/e effort to contact important person. - Morbid Jea ousy (1the o syndro&e)? fi)ed *elief that their spouse has *een unfaithful4 collect e(idence for se)ual acti(ity 5 restrict partner+s acti(ity4 may result in (iolence. - Persecutory? ost common type4 others are attempt to harm4 to o*tain legal recourse - <randiose? special role! relationship! a*ility! in(ol(ed in religion. - So&atic? delusion *elief a*out *ody (a*normal genitalia) to in!estation$ ('orms cra'ling in the *ody) - Fo ie a deu4 7 shared delusion *et'een hus*and and 'ife (close relationship) De usiona &isidenti!ication syndro&e? "a'gras de usion Frego i de usion 6ther ha(e *een Someone they /no' identified *y identical in disguise and or near identical harming him imposter +.$ 7'ide&io ogy - "ncommon$ 0.02> 7 0.0:= - ean age$ ?0 7 ?L years - "sually e2ual in and D4 or*id Fealousy more common in alcoholic male4 #rotomania more common in female +.) Ris: !actors and aaetio ogy - ad(anced age! isolation! lo' social status! premor*id ersponality disorder! sensory impairment! su*stance a*use! family history! history of Head ,nFury! ,mmigration - &emporal lo*e epilepsy! +.+ Pathogenesis? - 9ortical damage$ paranoid delusion - Aasal ganglia 7 less cogniti(e distur*ance - Dolie a deu)$ one dominant and one su*missi(e partner in a relationship +.- " inica !eatures? - Delusions are highly implausi*le! - 'ith e(idence of systemati0ation (*etter organi0ed than S1 delusion)4
Dr. Roger Ho
- huge impact on *eha(iour! - a*normal process in arri(ing conclusion +., Diagnosis? DS ,C re2uires M < month duration +.. Di!!erentia diagnosis Doung 'atients 1 d 'atients - Su*stance induced - Dementia- memory (stimulant! loss hallucinogen) - ood disorder 'ith - Delirium$ change in delusion (mood consciousness *efore delusion) - Schi0ophrenia (less - @ate onset ela*orated delusion) psychosis ('ith - 69D$ reality testing hallucination) is intact - Paranoid personality disorder (@ess clearly circumscri*ed delusion) +.3 (ssess&ent . thorough history and S# 9ollateral history from :rd party &o rule out organic causes Document ris/ assessment
"h. -
Bi'o ar disorder
-.# The a!!ecti/e s'ectru& - Dysthymia 7 not meeting criteria of depression - Depression - .typical depression$ hypersomnia! hyperphagia - Psychotic depression - Recurrent depression - Aipolar ,, 7 Hypomania - Aipolar , 7 ania - Rapid cycling M ? episodes per year - "ltra 7 rapid cycling$ (ery rapid changes -.$ 7'ide&io ogy - @ifetime pre(alence$ 2.) B #.-H - N D in pre(alence - Aipolar ,, 3 rapid cycling$ more common in Demale - ean age of onset$ $# years o d -.) (etio ogy - <enetics? <st degree relati(e are I) more li/ely to de(elop this condition. - 9hildren of a parent 'ith *ipolar disorder ha(e a >0= chance of de(eloping psychiatric disorder - 1$D1 ?>=$ 2:= -.+ Pathogenesis - Noradrenaline! dopamine! serotonin! 5 glutamine ha(e all *een implicated. - (ntide'ressant induced mania or hypomania is common. -.- " inica !eatures Hypomanic episode$ .N,.9 (9linical s/ill training) Dor mania! on top of .N,.9! they also ha(e$ - se(ere enough to interfere social 5 occupation function. - Psychotic features related to grandiosity. - Dlight of idea! Pressure of speech - Racing thought - Aeha(iours 'ith serious conse2uences$ rec/less spending! inappropriate se)ual encounters! careless in(estment. -., Diagnosis DSM IV diagnosis
+.0 Manage&ent - .dmission to hospital if there is a ris/ to self or (iolence to others. - Separation from source or focus of delusion - .ntipsychotics$ atypical$ less side effect - Aoth risperidone and Haloperidol ha(e li2uid form$ for those refusing ta*lets - Aen0odia0epine to treat an)iety Psycho ogica treat&ent - Su''orti/e 'sychothera'y$ to esta*lish therapeutic alliance 'ithout confronting - "ogniti/e techni=ues$ gently challenge delusion - Socia s:i training - I&'ro/ing ris: !actors$ sensory deficits! isolation +. #2 Prognosis Re&ission I&'ro/e&ent ::->0= <0= Persisting ::->0=
Aetter prognosis if it is acute4 Poor prognosis if delusional disorder last longer than ; months.
Dr. Roger Ho
- Bi'o ar I disorder? occurrence of < or more manic episode 'ith or 'ithout history of < or more depressi(e episode. - Bi'o ar II disorder 7 occurrence of < or more depressi(e episode accompanied *y at least < hypomanic episode. -.. DDE? - Su*stance a*use (if young) - 6rganic$ thyroid! cushing! S@#! head inFury - Psychotic disorders (if psychotic features) - Schi0oaffecti(e disorder (prominent psychosis) - .n)iety disorders -.3 In/estigation - DA9! #SR - @D&! RD&! &D&! glucose - CDR@ - "rine drug screen - 9&3 R, to rule out space occupying lesion! infarction! haemorrhage - ##E to rule out epilepsy 6ther tests$ - .ND to rule out S@# in ladies - "rinary copper to rule out 8ilson disease -.0 Setting o! Treat&ent? "sually re2uire admission for manic episode4 'ard has to *e calm 'ith less stimulation. Indications !or ad&ission inc ude? - High ris/ of suicide or homicide - @ac/ of capacity to cooperate 'ith treatment - Poor psychosocial supports - Se(ere psychotic symptoms - Se(ere depressi(e symptoms - Rapid cycling - Dailure of outpatient treatment <oa s o! out'atient treat&ent - #sta*lish 5 maintain therapeutic alliance - monitor psychiatric status - Psychoeducation for *ipolar disorder - #nhancing treatment adherence - onitoring side effects of medication - Promoting regular sleep and acti(ity - ,dentify ne' episodes early
-.0 Phar&aco ogica Manage&ent (cute treat&ent o! &anic 'hase ? By anti'sychotics? Haloperidol >-<0mg daily4 Risperidone 2- ?mg daily 6lan0apine (more sedati(e 5 good for mood symptoms *ut e)pensi(e)$ >- <0mg daily &hen add on mood sta*ili0er after *lood in(estigations. 6ithiu& "R (-22&g B #222&g F2.)>2.,) Be!ore starting ithiu&5 RD& 5 &D& ha(e to *e normal. Mechanis& o! action ? - By sti&u ating NaCK 'u&'5 stimulates entry of Na into the cells 'here intracellular Na is reduced in manic state4 stimulates e)it of Na from cells 'here intracellular Na is ele(ated in depressed state. - Inhibits both cyc ic (MP and inosito 'hos'hate second messenger system in the mem*erane. Indications? - Dor depression! manic states - Prophyla)is of *ipolar disorder - not useful for rapid cycling (d/erse e!!ects? > Short ter& side e!!ects$ E, distur*ances (nausea! (omiting! diarrhea) > 6ong ter& side e!!ects$ nephrogenic dia*etes insipidus due to *loc/age of .DH sensiti(e adenyl cyclase! hypothyroidism and cardioto)icity > To4ic e!!ects (refer to appendi) >a)$ @ithium o(erdosage can *e fatal. - 7bstein ano&a y in foetus. Sodiu& /a 'orate (7'i i&) (+22&g B #222&g) (F2.- B #) Aefore starting Calporate! chec/ @D& Mechanis&s - mediate its therapeutic effect *y indirect inhi*itions on E.A.ergic systems. Indications? - &reatment of depressi(e and manic episodes - Prophyla)is of *ipolar affecti(e disorder - Dor rapid cycling disorder
Dr. Roger Ho
(d/erse e!!ects? - Slight ris/ of li(er! pancreatic to)iciety - Haematological distur*ance of platelet function4 Neura tube de!ect in foetus "arba&a*e'ine +22B 322&g (F2.$>2.+) 9hec/ DA9 *efore starting car*ama0epine Mode o! action? - ediate its therapeutic effect *y inhi*iting /indling phenomena in the lim*ic system Indications? - Depression - Prophyla)is of *ipolar affecti(e disorder (d/erse e!!ect? - Dro'siness and di00iness - @eucopenia and other *lood disorders 6a&otrigine -2 B #-2&g #22&g L F) Dor *ipolar disorder 'ith depressi(e episodes -.#2 Psycho ogica Manage&ent - "ogniti/e thera'y to challenge grandiose thought - Beha/ioura thera'y to maintain regular pattern of daily acti(ities - Psychoeducation on *ipolar disorder - Damily therapy$ Psychoeducation for family 5 techni2ues to cope 'ith patient+s illness - Re a'se dri s$ to identify symptoms and to formulate a plan to see/ help in early manic phase. - Su''ort grou' for *ipolar patients. -.## 1ther treat&ent - 7"T? Aest for acute mania! failure to drug treatment! for pregnancy (to a(oid teratogenic effects) -.#$ "ourse and Prognosis? -#)tremely /ariab e -Dirst episode may *e hypomanic! manic! mi)ed! or depressi(e - @ength of time *et'een su*se2uent episodes may *egin to narro8 *ut sta*ili0e at ?th to >th decade. - "ntreated patients ha(e M <0 episodes in a lifetime. - &reated patients ha(e *etter prognosis -.#) "o&' ication? - or*idity and ortality rates are high? lost 'or/! lost producti(ity! di(orce! attempted suicide 2>->0= 5 committed suicide$ <0=
"h. , De'ressi/e Disorder

,.# 7'ide&io ogy (ge? 8omen! highest pre(alence *et'een :> and ?> years4 en increases 'ith age Se4? D$ N 2$< Socia c ass? more common in , (rich)! ,, and C (poor) ore common among di(orced! separated Pre(alence$ >= ,.$ (etio ogy? - <enetics$ Pre(alence in first rate relati(es$ <0<>= - Monoa&ine theory o! de'ression$ depletion of monoamine such as >H& 5 N. - 7ndocrine abnor&a ities$ hypersecretion of cortisol! decreased &SH Psycho ogica theory? - Materna de'ri/ation 'hen young - 6earned he ' essness? highly a(ersi(e outcomes are possi*le.- "ogniti/e distortions? <) .r*itrary inference$ dra'ing conclusion 'hen there is no e(idence. 2) Selecti(e a*straction 7 ignore important feature :) 6(er-generalisation from single incident ?) inimisation positi(e and magnitification of negati(e Socia theory? for 'omen! (Aro'n 5 Harris) -: or more children under <> yr of age -not 'or/ing outside -lac/ of supporti(e relationship from hd. -loss of mother3separation *efore age << -&hreatening life e(ent *efore depression ,.) " inica !eatures? > D#P#SS,6N 7 refer to clinical s/ills -Se(ere depression may ha(e psychotic features$ -Delusions concerned 'ith themes of 'orthlessness! guilt! ill-health! po(erty -Persecutory delusion$ people are a*out to ta/e re(enge on him - Hallucination$ second person auditory hallucination$ repetiti(e 'ords 5 phrases ,.+ DDE? - ,s it mi)ed an)iety 5 depressionO - ,s it *ipolar disorderO - #ndocrine$ hypothyroidism - edication related$ antihypertensi(e! steroid - .lcohol a*use ,.- In/estigations? DA9! #SR! A<2! Dolate! RD&! @D&! &D& ,., Phar&aco ogica Manage&ent? Se ecti/e serotonin reu'ta:e inhibitors SSRI
Dr. Roger Ho
-F uo4etine (Pro*ac) 20mg 6 (H0.2) for retarded depression4 ad(erse effect$ Restlessness4 @ong half life! a(oid in elderly 'ith a lot of medication4 (first line no'adays) - F u/o4a&ine (Fa/erin) >0mg -<00mg 6N4 H0.> Sedati(e4 high incidence of nausea 5 (omiting in first fe' days. - Paro4etine "R (Sero4at) 2>mg 6N! H2$ good for mi)ed an)iety 5 depression4 more 'ithdra'al symptoms - 7scita o'ra& ( e4a'ro) <0mg 6N! H<.>4 less drug interaction! good for elderly - Setra ine (@o o!t) >0 7 <>0mg 6N4 H<.8 -Noradrenergic and s'eci!ic serotonergic antide'ressants (NaSSas)? irta0epine (Remeron) <>-:0 mg 6N (H<-2)4 >H&-2 and >H&: postsynaptic receptor antagonist 5 antihistamine effects. - good for depression and insomnia - dro'siness and 'eight gain - No serotonin related side effects$ se)ual dysfunction! insomnia! agitation! nausea - No cardio(ascular or anticholinergic side effects - Serotonin % Noradrena ine reu'ta:e inhibitor? Vena !a4ine (7!e4or) I> mg AD H>.;4 second line! high dose hypertension Du o4etine("y&ba ta) ;0mg 6N for pain 5 depression - T"(? a&itri'ty ine >0 7 <00mg 6N! cardioto)icity 'hen o(erdose! anticholinergic side effects4 M(1I? seldom used - 7"T$ for acti(ely suicidal patients! not eating 5 drin/ing! treatment resistant depression -#9& has 'ide range effects on monoamine -.*solute contraindication$ raised ,9P -Relati(e contraindications$ cere*ral aneurysm! recent ,! cere*ral haemorrhage! retinal detachment. -7ar y side e!!ects$ loss of short term (retrograde) memory! headache! confusion! muscle aches >6ate side e!!ect$ long term memory loss ortality of #9&$ 23<00! 000 ,.. Psycho ogica Treat&ent "BT? "ogniti/e$ ,dentify cogniti(e dysfunctions from dysfunctional thought diary4 patient 'ill e)amine e(idence for and against them4 cogniti(e restructuring to change distorted thought4 Beha/ioura ? increase pleasura*le acti(ities.
"h. . 1bsessi/e "o&'u si/e Disorder ..# 7'ide&io ogy - 6nset is most commonly in early adult life - #2ually common among men and 'omen - Pre(alence 0.0>= ..$ (etio ogy - Eenetic$ 1$ D1 80=$ 2>= - 6rganic factor$ during epidemic of encephalitis lethargica - Premor*id personality$ I0= of 69D patients ha(e o*sessi(e compulsi(e personality trait- cleanliness! orderliness! rigid! chec/ing ..) Pathogenesis - Dysregulation of the >H& system - 9ell immediated autoimmune factors - 9&3 R,$ *ilateral reduction in caudate nucleus. - Psychological e)planation$ 69D patients ha(e defecti(e arousal system and ina*ility to control unpleasant internal states. 6*sessions (fear of dirt) are stimuli associated 'ith an)iety pro(o/ing e(ents 'here compulsions (such as hand 'ashing) are learned to reduce an)iety. ..) " inica !eatures 1BS7SSI1N B DIRT Doubts? repeating themes e)pressing uncertainty a*out pre(ious actions$ turned off the tap or not I&'u ses 7 Repeated urges to carry out actions that are usually em*arrassing or undesira*le e.g shout o*scenities in church Ru&inations 7 repeated 'orrying themes of more comple) thought 7 the end of the 'orld. Thought 7 repeated and intrusi(e 'ords or phrases "o&'u sions B "s (refer to clinical s/ills training) . co&'u sion is usually associated 'ith an o*session as if it has the function of reducing the distress caused *y o*session. #.g o*sessional thought 'ith hand contamination! associated 'ith hand'ashing compulsion. ..+ DDE? - .n)iety disorders - Pho*ic an)iety disorders - Psychotic disorders
10
Dr. Roger Ho
6rganic disorders Depressi(e disorders
"h. 3
(n4iety Disorders (14 handboo:)
..- Phar&aco ogica treat&ent - SSRIs are indicated in the treatment of 69D. 69D re2uire higher doses of SSR,s compared to depression. - Dlu(o)amine (Da(erin) <>0mg 7 200mg - Dluo)etine (Pro0ac) ?0mg 7 ;0mg - Paro)etine 9R (Sero)at) 2>mg 7 I>mg$ for (ery an)ious patients. .., Psycho ogica treat&ent "ogniti/e thera'y$ to use dysfunctional thought diary to record o*sessions and gently challenge o*sessional thought. Beha/ioura thera'y$ #)posure and response pre(ention. &his techni2ue in(ol(es e)posing patient to situations they a(oid such as dirty places and the patient is su*se2uently pre(ented from carrying out the usual compulsi(e cleansing rituals until the urge to do it has passed (response pre(ention) Thought sto''ing$ &he patient is as/ed to ruminate and upon doing so! the therapist shouts PstopQ to teach the patient to interrupt the o*sessional thought. &he patient then learns to internali0e the PstopQ order so that thought stopping can *e used outside therapy situation. Rehabi itation - to maintain functional capacity4 aintain their strengths - Promote adaptation to e(eryday li(ing. ... Socia treat&ent 6*sessional patients often in(ol(e other family mem*ers in their rituals. ,n planning treatment! it is essential to inter(ie' relati(es and encourage them to adopt a firm *ut sympathetic attitude to the patient. ..3 Prognosis - Poor 'rognosis? Ei(ing in to compulsions! longer duration! early onset! *i0arre o*session 5 compulsion! comor*id delusion and depression - <ood 'rognosis$ good premor*id!function a precipitating e(ent. 69D does not associate 'ith suicide.
3.# <enera ised (n4iety Disorders 7'ide&io ogy? -@ifetime pre(alence$ 2.>-;.?= -DemaleM ale - #arly onset$ 'ith childhood fears - @ate onset$ stressful life e(ents (etio ogy? - Eenetics$ Herita*ility$ :0= - ,ncrease .NS responsi(eness - @oss of control of cortisol - R E.A. acti(ity - dysregulation of >H& acti(ity - "ne)pected negati(e e(ents eg early death of parent - 9hronic stressors " inica !eatures (at east +) -.utonomic arousal$ s'eating! sha/ing -Physical$ *reathing difficulty! cho/ing! nausea! s'allo'ing difficulty - ental$ di00y! fainting! derealisation! depersonali0ation -Eeneral$ num*ness! tingling -&ension$ muscle!ache! /eyed up -6ther$ mind going *lan/! poor concentration DDE? - normal 'orries - mi)ed an)iety and depression - .lcohol 5 drug a*use - 6rganic$ &hyroid disorder! .rrhythmia! .sthma! &emporal lo*e epilepsy! hypoglycemia. In/estigation$ DA9! @D&! RD&! &D&! glucose! #9E Manage&ent? -Psychological$ rela)ation therapy. -Pharmacological$ short term *en0odia0epine! SSR, (a(oid fluo)etine)! propranolol for palpitation "ourse? -9hronic and disa*ling! lo' remission rate -9an lead to alcohol a*use. 3.$ Panic disorder 7'ide&io ogy? @ifetime pre(alence$ ?.2= 8omen$ 2-: times higher than men 2 pea/s in 'omen$ <>-2? yr4 ?>->? yr
11
Dr. Roger Ho
(etio ogy$ - Eenetics$ :0-?0= herita*ility -Supersensiti(ity of >H&<. receptors - ,ncreased adrenergic acti(ity - Decreased in E.A. 7 inhi*itory - Dear net'or/ in *rain$ amygdala " inica !eatures -Palpitations! S6A! cho/ing! sha/ing - .utonomic arousal - Dear of losing control -9oncerns of death from cardiac 5 respiratory pro*lems DDECIn/estigations? similar to E.D Psycho ogica Manage&ent? Beha/ioura ? use of rela)ation 5 control of hyper(entilation "ogniti/e &ethod? teaching a*out *odily responses associated 'ith panic attac/ Phar&aco ogica ? -SSR,$ paro)etine! fluo)etine! flu(o)amine are recommended drug of choice - A1Ds$ alpra0olam 0.>mg for acute attac/ Hy'er/enti ation Syndro&e (HVS)? - Cery common4 more common in Demale - >0-;0= of patients 'ith panic disorder ha(e HCS - Hyper(entilation4chest pain4di00iness4 *loating4 acute hypocalcaemia - &reatment$ esta*lish normal *reathing pattern! *en0odia0epine4 *reathing into paper *ag is not recommended no'adays as 962 can trigger more an)iety. (gora'hobia? (housebound house8i!e) <>-:> yr old4 more common in 'omen Dear of shops! mar/ets! *us! R&! cro'd! place that cannot *e left suddenly Socia 'hobia <I-:04 N D4 a(oid situations that can *e o*ser(ed *y others (presentation! ha'/er centre! R&) 5 'orries of humiliating or em*arrassing Manage&ent? short term *en0odia0epine! SSR, Syste&atic desensiti*ation? imagine or e)pose to an)iety pro(o/ing situations! progress through hierarchy! neutrali0e *y rela)ation techni2ue until patient ha*ituates
"ha'ter 0 Post trau&atic stress disorder 0.# 7'ide&io ogy - .fter traumatic e(ent! 8-<:= for men! 20 -:0= for 'omen de(elop P&SD - @ifetime pre(alence 8=. - D$ N 2$< 0.$ (etio ogy - <enetic$ higher concordance in 1 than D1 t'ins - Reduced right hi''oca&'a /o u&e5 enhanced reacti(ity to stimulation 5 memory deficits - Dysfunction amygdala lead to enhanced fear response Ris: !actors? -@o' education -@o'er Social class -Demale gender -@o' self esteem -Damily history of psychiatric disorders - Pre(ious trauma Protecti/e !actors - High ,J - High social class - ale - 9hance to (ie' *ody of dead person
0.) " inica !eatures ((''endi4 0a) - P&SD is a se(ere psychological distur*ance follo'ing a traumatic e(ent characteri0ed *y in(oluntary re-e)periencing of the e(ents! 'ith symptoms of hyperarousal! a(oidance and flash*ac/s of e(ents. @onger than ? 'ee/s. 0.+ DDE - .cute stress reaction - .dFustment disorder 0.- Psycho ogica treat&ent > "BT$ education a*out P&SD! an)iety management! anger management! cogniti(e restructuring for trauma e)perience! gradual e)posure to stimuli a(oided - Psychodyna&ic thera'y? understand the meaning of trauma! to resol(e unconscious conflict. - 7ye &o/e&ent desensiti*ation % re'rocess? "sing (oluntary multi-saccadic eye mo(ements to reduce an)iety (limited e)perience in Singapore! don+t mention it in oral e)am) - @oo/ for alcohol a*use 0., Phar&aco ogica treat&ent - Depressi(e symptoms$ SSR, - .n)iety symptoms$ 2 'ee/s alpra0olam 0.2>mg &DS
12
Dr. Roger Ho
0.. "o&' ication - >0= reco(er <st year4 :0=$ chronic (cute Stress Reaction (hrs to days)$ . transient disorder (hrs or days) that occur as immediate response to e)ceptional stress! accident! assault! fire! *erea(ement). 9linical features$ depression and an)iety. (cute Stress disorder ($d B + 8ee:s) Similar to acute stress reaction! *ut more dissociati(e symptoms Similar to P&SD! *ut less than ? 'ee/s duration. (dJust&ent disorder () &o B , &o) ,t occurs 'ithin : months of a particular stressor 5 should not last longer than ; months after the stressor is remo(ed. anifested as depression and an)iety (no psychotic features). Treat&ent o! abo/e disorders? Supporti(e psychotherapy to enhance capacity to cope! understand meaning of stressors. Pharmacological$ SSR,! short term A1D Nor&a and abnor&a grie! reactions - Berea/e&ent? any loss e(ent - Nor&a grie!? refer to appendi) La ean duration$ ; months. - (bnor&a grie!? <) ,ntense 2) ProlongedM < year :) Delayed grief ?) .*sent grief 6ther features$ thoughts of death! e)cessi(e guilty! mar/ed psychomotor retardation! prolonged impairment of function! hallucination. Manage&ent? - Short ter& ben*odia*e'ine? alpra0olam 0.2>mg &DS for 2 'ee/s - .ntidepressant if there are depressi(e symptoms - Su''orti/e 'sychothera'y$ enhance coping - <rie! thera'y? e)plore the meaning of the loss! let go of the past and mo(e to'ards the future. Ref$ 6)ford Hand*oo/! 200?
"h. #2 ( coho de'endence #2.# De!inition o! de'endence? <) Su*Fecti(e a'areness of co&'u sion to drin/ 2) Stereoty'ed 'attern of drin/ing :) ,ncreased to erance to alcohol ?) Pri&acy of drin/ing o(er other acti(ities >) Repeated 8ithdra8a sy&'to&s ;) Re ie! drin:ing I) Reinstate&ent after a*stinence #2.$ 7'ide&io ogy (ge$ men in their early t'enties Se4$ ore common in male4 increasing incidence in females. Socia c ass$ lo'est pre(alence in middle social *lass Marriage$ more common in di(orce3separated 1ccu'ation? high ris/$ directors! doctors. #2.) (etio ogy? - <enetic !actors? 1 M D1 t'ins! adoption study also pro(es genetic lin/s. - .*normal neurotransmitter mechanism - @earning factors$ learn from peer 3 parents - Persona ity !actors? chronic an)iety! feeling inferior. - 6ther illness$ an)iety disorder! depression #2.+ " inica !eatures (a''endi4 #2) ( coho into4ication? e)plosi(e out*ursts of aggression! short term amnesia after hea(y drin/ing! idiosyncratic reactions to alcohol! pathological drun/enness$ acute psychosis induced *y small amount of alcohol <enera 8ithdra8a sy&'to&s? #$>$+ hr - .cute tremulousness in hands (the sha/e) - .gitation! s'eating - Nausea - Perceptual distortions 5 hallucinations - 9on(ulsions De iriu& tre&ens? )>+days - 9louding of consciousness - Disorientation in time 5 place - ,mpairment of recent memory - ,llusions 5 Hallucinations - Dearful affect - Prolonged insomnia - &remulous hands - &runcal ata)ia - .utonomic o(eracti(ity ( coho ic ha ucinosis
13
Dr. Roger Ho
-occurs in clear consciousness -(oices utter insults or threats! - 9auses an)iety in patients In4? DA9! @D&! "5#! EE&! 9SR! glucose #2.Manage&ent Deto4i!ication? &anaging 8ithdra8a - Dia0epam >mg &DS! Citamin! thiamine :0mg 6 ! A<2! Rehydration. Moti/ation inter/ie8ing to help patient to change. Stages o! change? precontemplation! contemplation! preparation! action! maintenance! relapse - Re!er to "(MP5 IMH Phar&aco ogica agents used !or &aintenance? - Disu !ira&? an a(ersi(e stimulus! inducing nausea if patient drin/s alcohol - (ca&'rostate$ 'or/s on E.A.3glutamate system! for maintenance - Na tre4one? opiate receptor antagonist! Psycho ogica treat&ent? Beha/ioura thera'y$ /eep diary log 5 tac/le drin/ing *eha(iour. Socia treat&ent? > <oa orientated treat&ent ' an? Tota abstinence$ M ?0! hea(ily dependent! physical damage! failed controlled drin/ing "ontro ed drin:ing$T ?0! not dependent on alcohol! no physical damage! early stage - ( coho ic anony&ous? o*ser(e 5 mirroring! de(elop coping strategies - Ha ! 8ay house? reha*ilitation! counselling #2., "o&' ications Nutritiona or to4ic disorders 9ernic:eMs Korsa:o!!Ms ence'ha o'athy 'sychosis 6phthalmoplegia ,mpairment of recent Nystagmus memory 9louding of 9onfa*ulation consciousness Retrograde amnesia emory distur*ance Disorientation .ta)ia #uphoria .lcohol dementia - Depression and suicidal *eha(iours - Polysu*stance a*use - Social complications$ Fo*! marriage <0.; Prognosis? good prognosis in moti(ated! socially sta*le! no antisocial personality disorder
"h. ## Drug De'endence ##.# De!inition? ,t is a state! resulting from the interaction *et'een a human and a drug! characteri0ed *y *eha(ioural and other responses that include a compulsion to ta/e the drug on a continuous or periodic *asis to e)perience its psychic effects 5 to a(oid discomfort. ##.$ Physica and 'sycho ogica de'endence Drugs Heroin Hallucinogen .mphetamine 9anna*is 9ocaine A1D Physica Ues No No No No Ues Psycho ogica Ues Ues Ues Ues Ues Ues
##.$ 1'iates B eg Heroin "hronic use 9ithdra8a 9onstipation Pilo-erection! 9onstricted pupils shi(ering 8ea/ness -.*dominal cramps ,mpotence -@acrimation &remors - Dilated pupils - ,ntense cra(e for drugs - .gitation Treat&ent? > Methadone? 20mg solution form! super(ised treatment. > Bu'renor'hine (Subute4) 'as listed as illegal drug 5 'ithdra'an from Singapore. ##.) Ha ucinogens B 6SD ( ysergic acid diethy a&ide) - #ffects occur after 2 hours of consumption. - Synaethesia$ confusion *et'een senses e.g hearing images - 6ut of *ody e)perience - .n)eity and depression - 9an lead to unpredicta*le 5 dangerous *eha(iour. ##.+ (&'heta&ines - 9hronic use can lead to paranoia - Hostility 5 aggression - Persecutory delusions - .uditory! (isual! tactile hallucination - 9lear consciousness
14
Dr. Roger Ho
##.- "annabis 7!!ects -#)aggerating e)isting mood -Distortion of time 5 space -,ntensification of (isual perception 5 (isual hallucination -Reddening of eye -,rritation of respiratory tract
"hronic e!!ects 9hronic amoti(ational syndrome. Dlash*ac/ phenomena Psychotic reactions
"h. #$ 1 d (ge Psychiatry #$.# ( *hei&erMs disease -most common cause of dementia (I0=) 7'ide&io ogy -<= at ;0! dou*les e(ery > years4 ?0= at 8> yr old - $D N ?$< - 6ther ris/ factor$ Do'n syndrome! head inFury! hypothyroid <enetics? - 9hromosome 2< for amyloid precursor protein - 9hromosome <L for apolipoprotein #? - 9hromosome <? for presenilin < - 9hromosome < for presenilin << "ho inergic hy'othesis? degeneration of cholinergic nuclei in nucleus of eynert Patho'hysio ogy -.myloid plagues in hippocampus! amygdale and corte) -Neurofi*rillary tangles in corte)! hippocampus " inica !eatures #arly symptoms$ increasing forgetfulness .mnesia .phasia ('ord finding difficulty) .pra)ia (cannot dress) .gnosia (cannot recogni0e *ody parts) Poor (isual spatial s/ill Delusion of theft against maid in S+pore Hallucination <0= Beha/ioura disturbance$ aggression! 'andering! se)ual disinhi*ition Mini>&enta state e4a& N $+ C)2 In/estigations? DA9! A<2! Dolate! @D&! RD&! CDR@! 9& or R, *rain Manage&ent? (cety cho inesterase inhibitors? FFF MMS7 O #$ 'oints Done'e*i ->#2&gCday? (-&gLF-) long half life! once daily dosage 'ith E,& side effects! not for asthma patients
##., "ocaine Dormication (cocaine *ugs) 7 e)am classic$ a tactile hallucination as feeling insects cra'ling under the s/in. &reatment of a*o(e disorders$ may need antipsychotics to treat psychotic e)perience. ##.. Ben*odia*e'ine e.g. Dormicum ( ida0olam)! .lpra0olam (Sana)) "hronic use 9ithdra8a "nsteady gait Re*ound insomnia Dysarthria .n)iety Dro'siness .ppetite distur*ance Nystagmus S'eating! con(ulsion 9onfusion! Delirium tremens Treat&ent? s'itch to long acting *en0odia0epines such as dia0epam >mg &DS and slo'ly cut do'n the dose. ay need in-patient deto)ication if using high dose *en0odia0epine. Psycho ogica treat&ent? > Su''orti/e 'sychothera'y? educate patients on complications of drug dependence and cope 'ith day to day pro*lems. - <rou' thera'y? o*ser(e their o'n pro*lems mirrored in other drug a*users4 'or/ out for *etter coping - Beha/ioura thera'y? /eep a diary of drug use and e)plore mood and feelings at the time of drug use 'ith therapist and to reduce the num*er of drug inta/e. - Rehabi itation in "(MP5 IMH? to lea(e the drug su*culture! support *y counselor.
15
Dr. Roger Ho
Ri/astig&ine )>,&g BD? (F$.,C)&g) short half life! E,& side effects and safe in asthma. <a anta&ine? ?-<2mg AD (8mg N H?.>)4 also 'or/s on nicotinic .ch receptors. Me&antine? N D. receptors partial antagonist (<0mg N H:) @o' dose antipsychotics such as risperidone <mg 6N for delusion of theft Beha/ioura techni=ues for chaging negati(e *eha(iour Poor 'rognosis? ale! 6nset T ;>! Parietal lo*e damage! prominent *eha(ioural pro*lems! Depression #$.$ 1ther causes o! de&entia - Dementia 'ith @e'y *ody ('ith par/insonism) - Dronto 7 temporal dementia 'ith personality changes - Cascular dementia 'ith neurological signs of stro/e #$.) Re/ersib e causes o! de&entia B (''endi4 #$a #$.+ Pseudo de&entia? a 8ays say5 PI donMt :no8Q - Pre(ious history of depression - ,slands of normality - Response to antidepressant #$.- Psychosis in e der y @ess than <=4 D$ >$< Damily history of schi0ophrenia4 sensory impairments! social isolation Persecutory delusions$ L0= .uditory hallucinations$ I>= Cisual hallucination <:= &reatment$ relie(e isolation 5 sensory deficits4 lo' dose atypical antipsychotics$ risperidone <mg 6N 3 2uetiapine >0mg 6N #$., De'ression in e der y - more psychomotor retardation - nihilistic delusion (9otard syndrome) - onitor suicide ris/ - &reatment of choice$ escitalopram <0mg 6N
"h. #) "onsu tation 6iaison Psychiatry #).# Dissociati/e C "on/ersion Disorders De!inition - Dissociation 7 an apparent dissociation *et'een different mental acti(ities. - "on/ersion > ental energy can *e con(erted into certain physical symptoms. 7'ide&io ogy? - 6nset usually *efore the age of :> - ore common among 'omen - ore common in lo'er social class - 6ccurs in national ser(icemen (etio ogy? - Premor*id personality$ <>= has premor*id histrionic personality traits. - #motionally charged ideas lodged in the unconscious at some time in the past. &here is a con(ersion of psychic energy into physical channels. Pathogenesis - Pri&ary gain? an)iety arising from a psychological conflict is e)cluded from patient+s conscious mind - Secondary gain? symptoms confer ad(antage to patient$ e)empted from NS. " inica !eatures? Dissociation - Psychogenic amnesia - Psychogenic fugue ('andering) -Somnam*ulism (sleep 'al/ing) - ultiple personality "on/ersion - Paralysis - Dits - Alindness - Deafness - .phonia. - .naethesia - a*dominal pain - Disorder of gait
6a Be e indi!!erence? less than the e)pected amount of distress often sho'n *y patients 'ith hysterical symptoms. DDE? - #)clude organic causes$ temporal lo*e epilepsy! cere*ral tumour! general paralysis of insane dementia - #)clude malingering$ conscious a'are of 'hat he or she is doing! ma/ing up illness - #)clude histrionic personality disorder. In/estigation? no demonstrata*le organic findings Manage&ent? Psycho ogica treat&ent? - reassurance and suggestion
16
Dr. Roger Ho
- e)ploratory psychotherapy a*out his past life. Socia treat&ent? to eliminate factors that are reinforcing symptoms. Bio ogica treat&ent? (breaction$ ,C inFection of small amount of dia0epam to put patient into resting state and encouraged to relie(e stressful life e(ent (last to mention in e)am) Prognosis? ,f the course is longer than < year! it is li/ely to persist for many years. Pseudosei*ure? - ,nconsistent neurological sign - 9an recall the sei0ure episode 5 a(oid inFury - no increase in serum prolactin (increases in genuine epilepsy) #).$ Hy'ochondriasis Hy'ochondriasis is the preoccupation 'ith the fear of ha(ing a serious disease 'hich persists despite negati(e in(estigation. 7'ide&io ogy ore common among elderly! e2ual se) incidence! lo'er social class (etio ogy? - History of childhood illness! parental illness! e)cessi(e medical attention see/ing in parents! childhood se)ual a*use - &endency to misattri*ute *ody symptoms - edical reassurance pro(ides temporary relief of an)iety 'hich acts as a re'ard for more medical attention. " inica !eatures? -Preoccupation 'ith the idea of ha(ing a serious medical condition! 'hich 'ill lead to death and serious disa*ility. - Patient 'ill see/ medical ad(ice *ut is una*le to *e reassured *y negati(e in(estigations4 - .n)iety 5 depression are common. - ,t is usually in the form of o(er(alued idea. Manage&ent - .llo' patient to (entilate their pro*lems - #)plain negati(e test! reassurance! no further in(estigation! - .im to impro(e function - Area/ cycle of repeat consultation - Damily education
- 9A&$ challenge 5 replace misinterpretation - #)posure to illness cue 5 response pre(ention - Depression$ use SSR, li/e fluo)etine So&atisation disorder . chronic disorder of multiple medically une)plained symptoms! affecting multiple organ systems presenting *efore the age of ?0. ,t is associated 'ith significant psychological distress. (etio ogy - ore family mem*ers 'ith somatisation disorder4 similar to aetiology of hypochondriasis. 7'ide&io ogy? - 0.2=4 D$ onset$ childhood to :0s >$<4 age of
" inica !eatures? Pain$ right iliac! *ac/ and head 9CS$ dyspnoea! chest pain! palpitation! AP E,$ heart*urn! nausea! flatulence! dysphagia S'eating or *ody odour Manage&ent? Initia ? -.c/no'ledge symptom se(erity 5 as real -.ttempt to reframe symptoms as emotional 1ngoing &anage&ent? -Regular re(ie' *y single doctor! planned (isit! a(oid .#D 5 unnecessary in(estigation - ,n(estigate o*Fecti(e signs only - Symptom re-attri*ution - 9A& Body dys&or'hic disorder (Dys&or'ho'hbia)? Preoccupation that some aspect of physical appearance (*ody image) is grossly a*normal 5 refuses to accept medical e)planation. &reated *y SSR, and 9A&. ,t can lead to depression! suicide! 5 functional impairment. Factitious disorder C MunchausenMs syndro&e? falsify symptoms 5 fa*ricate signs (use /etchup for *lood) for medical attention "a'acity to gi/e consent <) Patient must *e informed a*out the procedure! ris/ and *enefit 2) 9an patient understand the infoO :) 9an patient retain infoO ?) 9an patient *alance the ris/ or *enefitO
17
Dr. Roger Ho
>) 9an patient arri(e at a conclusionO ;) Durther assessment of cogniti(e function e.g mini mental state e)amination. I) Ha(ing a psychiatric illness li/e Schi0ophrenia does not mean lac/ of capacity to gi(e consent. De iriu&C (cute con!usiona state ,t is a clinical syndrome of fluctuating glo*al cogniti(e impairment 'ith *eha(ioural a*normalities due to (ariety of insults. 7'ide&io ogy <0= of medical 5 surgical inpatients. Ris: !actors$ elderly! dementia! *lind 5 deaf! postoperati(e! *urn (ictims! alcoholic. (etio ogy -Intracrania ? 9C.! head inFury! 9NS infection - &etabo ic? electrolyte distur*ance! hepatic encephalopathy! hypo)ia - endocrine? Pituitary! thyroid! P&H! adrenal - In!ection? "&,! chest infection! a*scess - Substance into4ication and 8ithdra8a " inica !eatures? - Dluctuating course -impaired consciousness and attention - Disorientation! impaired recent memory - Nocturnal 'orsening of symptoms - Psychomotor agitation 5 emotional la*ility - illusions! (isual hallucinations (*ig insect) - Poorly formed paranoid idea (other patients 'ant to harm him) DDE? > Psychotic illness - Post ictal confusion - Dementia Manage&ent? 1) ,dentify 5 treat precipitating cause 2) Pro(ide calm en(ironment 'ith reality orientation (*ig cloc/) 3) @o' dose antipsychotics$ Haloperidol 2.>mg3 risperidone <mg 4) Regular re(ie' and follo' up 5) #ducate family a*out delirium De'ression in chronic &edica i ness - 9ommon! @oo/ for non somatic symptoms$ guilt! concentration! lo' mood - .ssess suicide ris/ - "se escitalpram as it has less drug interactions.
"h. #+ Perinata Psychiatry #+.# Baby b ues
V of ne' mothers 'ill e)perience a short li(ed period of tearfulness and emotional la*ility starting 2-: days after *irth. Due to pospatrum reductions of oestrogen! progesterone and prolactin. No need for treatment. #+.$ Postnata de'ression
7'ide&io ogy? - <0-<>= of 'omen - Pea/$ :-? 'ee/s of deli(ery Ris: !actors? - Damily history of depression4 - Poor relationship 'ith o'n mother - .m*i(alence to'ards pregnancy - Poor social support - Pre(ious postpartum depression " inica !eatures - Depression B 'orries a*out *a*y+s health and a*ility to loo/ after *a*y - L0= last less than < month Manage&ent? - Pre(ention *y education - #nhance support - ,f se(ere! SSR, (to a(oid *reast feeding) - 9A& #+.) Post'atru& 'sychosis
7'ide&io ogy <.>3<000 li(e *irths Pea/$ 2 'ee/s postpartum (etio ogy Reduce of oestrogen! leading to dopamine super-sensiti(ity! cortisol le(els or postpartum thyroiditis Ris: !actors? - Damily history of psychiatric disorder - @ac/ of social support " inica !eatures?
18
Dr. Roger Ho
-Prominent affecti(e features (80=)$ mania 3 depression - Psychosis! paranoid idea a*out safety of *a*y - ,nsomnia! perple)ity! disorientation - @oo/ for suicide 5 infanticide ris/ Manage&ent? &reatment in hospital 7 WW 'omen hospital 3 ,n the "W! admit to special mother 7 *a*y unit #9& is useful .ntipsychotics is needed ( to a(oid *reast feeding) #+.+ Pre&enstrua Syndro&e (PMS)
"h. #-
7ating disorder
#-.# (nore4ia Ner/osa 7'ide&io ogy - "sually Demales4 D$ N <0$< -6nset *et'een <;-<I - ore common in upper social class - <= of middle class adolescent girls. - ,ncreasing incidence$ 0.>= (etio ogy -Eenetics$ 1$ D1 ;>=$:2=4;-<0= of female si*lings of patients also suffer from this condition -Hypothalamic dysfunction - Social$ #)am stress in S+pore! occupations group$ *allet students! atheletes -,ndi(idual pathology$ dietary pro*lems in early life! lac/ of a sense of identity - Damily pathology$ enmeshment! rigidity! o(erprotecti(ieness! lac/ of pro*lem sol(ing " inica !eatures "ore c inica !eatures > R(PID -. *ody 'eight more than <>= *elo' the standard 'eight or A , <I.> or less - Self induced 'eight loss$ (omiting! purging! e)cessi(e e)ercise! appetite suppressant -Aody image distortion- dread of fatness! o(er(alued idea -#ndocrine disorder$ HP. a)is! amenorrhoea! reduced se)ual interest! raised cortisol! altered &D&s - Delayed and arrested pu*erty. "o&' ications? Secondary to star/ation Hypothermia 9onstipation @o' AP! anaemia Aradycardia .menorrhoea @eucopenia Hypercholesterolemia Delayed in gro'th 6steoporosis Dry s/in3*rittle hair @oss of *rain (olume 9ere*ral atrophy Centricle "onse=uences o! /o&iting % a4ati/e Hypo/alaemia Hyponatraemia Prolonged J& 9ardiac arrhythmia Dental caries
P S is a constellation of menstrually related! chronic! cyclical! physical and emotional symptoms in the luteal phase. Sy&'to&s$ Areast tenderness! fatigue! cramping! *loating! irrita*ility! depression! poor concentration! food cra(ings! lethargy! li*ido changes. Pre/a ence? ?0= of 'omen of reproducti(e age! se(ere impairment in >= In/estigation? 9harting of daily symptoms for at least 2 menstrual cycle may aid in confirming cyclical pattern. Treat&ent? "onser/ati/e &anage&ent? @o' salt and fat diet! less caffeine! reduce alcohol and to*acoo inta/e! to reduce stress "onsider &edication? to try SSR, if fails to conser(ati(e treatment. Re!er to 1 and < i! abo/e &easures !ai
Ref$ 6)ford Hand*oo/! 200?
19
Dr. Roger Ho
enlargement 7 e/ated hor&ones Ero'th hormone Prolactin 9ortisol Reduced hor&ones &: and &? 6estradiol &estoesterone DSH and @H
Phar&aco ogica ? 6lan0apine may *e used to promote 'eight gain (contro(ersial not to mention in e)am) Prognosis o! (N Ru es o! one third$ #C) #C) Reco(er fully Reco(er partially #C) 9hronically disa*led.
In/estigation DA9! RD&! @D&! glucose! &D&! cholesterol! @H! DSH DDE? Functiona i ness 69D Depressi(e disorder 1rganic disorder Hypopituitarism &hyroto)icosis Dia*etes ellitius Arain tumour ala*sorption
Factors associated 8ith a 'oor 'rognosis - 9hronic illness - @ate age of onset - Aulimic features - .n)iety 'hen eating 'ith others - #)cessi(e 'eight loss - Poor childhood social adFustment - Poor parental relationships ale se) Bu i&ia Ner/osa 7'ide&io ogy? <= of 'omen (etio ogy? Damily history of affecti(e disorder Serotonergic dysregulation " inica !eatures? -Persistent preoccupation 'ith eating -,rresisti*le cra(ing for food -*inges$ episodes of o(ereating - .ttempts to counter the fattening effects of food$ self induced (omiting! purging BN is di!!erent !ro& (N. In BN5 - Patients are more eager for help enstrual a*normalities less than half of the patients - Aody 'eight 'ithin normal limits "o&orbidity? Mu ti' e dyscontro beha/iours? - 9utting 3 *urning - 6(erdose - .lcohol 3 drug misuse - Promisuity Manage&ent - "sually managed as outpatient - .dmission only for suicidality and physical pro*lems - Higher dose of SSR,$ fluo)etine up to ;0 mg - 9ogniti(e *eha(ioural therapy
Manage&ent? (d&ission to hos'ita ? -#)tremely rapid or e)cessi(e 'eight loss -Se(ere electrolyte im*alance - 9ardiac complications - ar/ed change in mental status - Ris/ of suicide - Dailure of outpatient treatment Feeding and re!eeding syndro&e -9onsult medical3dietitian - Refeeding syndrome$ 9ardiac decompensation can occur 'ithin first 2 'ee/s$ myocardium cannot 'ithstand the stress of increased meta*olic demand4 slo'ly increase dietary inta/e *y 200/cal per day and monitor RD& closely Psycho ogica treat&ent? >Su''orti/e 'sychothera'y? to impro(e interpersonal relationships and sense of personal effecti(eness. - Beha/ioura thera'y? regimen of refeeding! to set target 'eight! positi(e reinforcement 'ith pri(ileges such as outing! mo(ie etc - "ogniti/e thera'y! after gaining some 'eight! aims at changing attitude to'ards eating! reappraisal of self image and life circumstances. -Fa&i y thera'y
20
Dr. Roger Ho
Poor 'rognosis$ se(ere personality disorder or lo' self esteem. #-.) Patho ogica ga&b ing ,t is a persistent and recurrent maladapti(e patterns of gam*ling *eha(iour. Relati(ely common and may lead to significant personal! family and occupational difficulties. " inica !eatures - Preoccupation 'ith gam*ling - &olerance$ need to gam*le 'ith larger amounts of money - Dail to cut do'n - 9hasing losses (li/e chasing the dragon in drug addicts) - @ying to others a*out gam*ling - 9ommitting illegal acts to finance gam*ling. - @osing or Feopardi0ing familial relationship Treat&ent$ - 9A& to reduce preoccupation 'ith gam*ling - SSR, (fluo)etine) - Support group - 9redit card de*t counseling (ia S8 #-.+ K e'to&ania Dailure to resist impulses to steal items that are not needed nor sought for personal use. e.g . men stole <0 female & shirts! same style *ut different colours. "sually 'omen! mean age :;! <; years of illness DDE? shoplifting ('ell planned and moti(ated *y need and monetary gain)! 69D and depression Treat&ent? - 9A& - SSR, #-.Trichoti o&ania Stereotyped recurrent pulling of hair DDE? 69D! &ourette syndrome! .utism! factitious disorder
Treat&ent? *eha(ioural modification! SSR,!if fail consider risperidone or lithium Ref$ 6)ford Hand*oo/! 200? "h.#, Suicide and DSH Tr!c)cycl!st, *K #,.# Suicide 7'ide&io ogy completers are more often $ male psychiatric disorder ha(e made a plan used a dangerous method Pre(alence l!fet!me +re$alence ("S.)$ 2< = mor*id thoughts <0.2 = suicidal thoughts 2.L = attempted suicide EP $ (2!>00 patients) < suicide e(ery ? years Psychiatrist (catchment area >0!000) < suicide e(ery : months Sociode&ogra'hic corre ates o! suicide %) ,"e, Sex a) $D N :$<4 males M females for all groups *) suicide pacts more common in the elderly -. Mar!tal status ( a) di(orced M 'ido'ed M single /. 0m+loyment ( a) unemployed 3 retired 3 li(ing alone 1. Soc!al Class ( a) Higher in lo'est social groups 5 professional *) lo'est in middle groups 2. 3el!"!on ( a) strong religious affiliation is a protecti(e factor 4. 5ccu+at!on ( a) higher ris/ groups are doctors! la'yers! hotel and *ar trade o'ners I. 9hronic Phys!cal !llness ( terminal illness 3 malignancies a) chronic pain '. 5ther assoc!at!ons ( a) history of DSH (<3:- X of completers)
21
Dr. Roger Ho
Suicide and &enta i ness all psychiatric illness (e)cept 69D) increase ris/ *y L0-L> = Depression (ris/ :.; - 8.> = N :0 ) general population ris/) Schi0ophrenia (ris/ > - <0 =) .lcohol dependence (ris/ :.? - ;.I =) Neurosis$ panic disorder3 P&SD S'ecia 'o'u ations #lderly rate increasing 80-L0 = of elderly suicides ha(e depressi(e illness often first episode of depression DSH is more closely associated 'ith completed suicide denial of suicide more common ,npatients Highest ris/ $ (etio ogy <enetics suicidal *eha(iour clusters in family 1 $ D1 N <<.: = $ <.8 = (Roy et al. <LL<) Neurochemical %)Seroton!n ( serotonin deficiency #,.$ De iberate se ! har& (DSH) . deli*erate! non fatal act! 'hether physical! drug o(erdose! or poisoning! done in the /no'ledge that it 'as potentially harmful. ore common in female Moti/es? . cry for help4 .n attempt to influence others4 escape from stress4 to feel pain in personality disorder first 'ee/ of admission early stages of reco(ery *et'een shifts of staff on lea(e (patients and staff) *an/ holidays discharge (premature) ris/ is increased :0 ) in the month after discharge
Factors o! DSH 'redicting suicida ris: ,solation4 timing precautions to a(oid inter(ention suicide note anticipatory acts Ydangerousness+ of state of mind
Persona ity disorder
"h. #.
Deeply ingrained! maladapti(e patterns of *eha(iour4 recognisa*le in early adulthood! continuing throughout most of adult life4 there is an ad(erse effect on the indi(idual or society. #..# Border ine Persona ity Disorder
Pre/a ence? <.> 7 2= "hi dhood de/e o'&ent 9hildhood trauma 7 se)ual a*use! di(orce Playing primiti(e defence mechanisms such as splitting or proFecti(e identification " inica !eatures? PI R(IS7 ( P(INQ , 7 ,dentity distur*ance R- Relationship$ unsta*le . 7 .*andonment fear of , 7 ,mpulsi(e S 7 Suicidal gesture # 7 #mptyiness . 7 .ffect$ unsta*le P 7 Paranoid idea 3 psychosis$ transient . 7 .nger , - ,dealisation and Dealisation N - Negati(istic Prognosis? <3: continue to ha(e Aorderline Personality disorder after <0 7 20 years. Poor 'rognosis? - Se(ere repeated self-harm #..$ (ntisocia Persona ity Disorder
Pre/a ence? 2-:.>= Neuro'hysio ogy? -immature ##E in posterior temporal lo*e as slo' 'a(es - @o' >H& le(els in impulsi(e (iolent indi(iduals "hi dhood de/e o'&ent Difficult infant temperament
22
Dr. Roger Ho
Harsh and inconsistent parenting 9onduct disorder in childhood
" inica !eatures? P"(661ISQ 9onduct disorder T <> .ntisocial .ct and aggression @ies fre2uently @ac/ superego 6*ligations not honoured "nsta*le and cannot plan ahead Safety of self or others ignored Prognosis? ay commit crime ay sho' ,mpro(ement *y >th decade Manage&ent o! Persona ity Disorder Ma:ing the diagnosis o! 'ersona ity disorder .ssess patient+s enduring and per(asi(e patterns of emotional e)pression! interpersonal relationships! social functioning 6*tain collateral information from family and past psychiatric history #)plore relationships! self concept and functional assessment (d&ission to hos'ita &hey *enefit little from prolonged admission. .dmission is indicated for specific crisis &reatment plan aims to set limits and to achie(e realistic goal Psycho ogica treat&ent -Super(ision and support are often *eneficial "BT? #ducate them a*out the schema #mpathetic challenging their core *eliefs Eoal directed pro*lem sol(ing approach Ref$ 6)ford Hand*oo/! 200? "ha'ter #3 Psychiatric 7&ergency
#3. # (cute disturbed 'atient (etio ogy - .lcohol and drug dependence - ,llicit drugs eta*olic distur*ance - Head inFury - Schi0ophrenia ania - Personality disorders Treat&ent o! acute disturbed 'atient or crisis? ,t re2uires immediate action$ <) De-escalation (er*ally in calm and consistent en(ironment. 2) 6ral medication$ P6 Haloperidol >mg stat or P6 lora0epam <mg stat :) , medication$ , Halperidol >mg stat4 , lora0epam 2mg (in , H)4 no , dia0epam due topoor a*sorption ?) 9lose monitoring on (ital sign >) ,f chemical restraint fails! consider physical restraint #3.$ Neuro e'tic Ma ignant Syndro&e
,t is a rare i!e threatening reaction to antipsychotic medication characterised *y fe(er! muscular rigidity! altered mental status and autonomic dysfunction. Due to b oc:ade o! D$ rece'tors leading to impaired calcium mo*ilisation and leads to muscle rigidity. Incidence? 0.2= D$ N 2$< Ris: !actors - Drug naZ(e patient recei(ing high potency antipsychotics - Dehydration " inica signs and sy&'to&s? - Hyperthermia uscular rigidity
Dia ectica beha/ioura thera'y !or border ine 'ersona ity disorder - Docus on a detailed 9A& approach to self harm - &hen focus on tolerance of distress! emotional regulation and interpersonal s/ills - &o process trauma - De(elop self esteem and realistic future goals Phar&aco ogica treat&ent? - SSR, antidepressant can impro(e mood and reduce impulsi(ity 1utco&e o! 'ersona ity disorder High rates of accident! suicide and (iolent death.
23
Dr. Roger Ho
- 9onfusion 3 agitation - &achycardia - Hyper or hypotension - &remor - ,ncontinence - K 9W le(el In/estigations? DA9! @D&! RD&! 9a and P6?! serum 9W! 9SR! 9& DDE? lethal catatonia! malignant hyperthermia! meningitis! heat e)haustion! rha*domyolysis Manage&ent? - Stop antipsychotics edical emergency! refer to medical - ,C fluids! reduce temperature - Aen0odia0epine for acute *eha(ioural distur*ance - &o gi(e *romocriptine Morta ity? >-20= die! it can lead to acute renal failure. #3.) Serotonin syndro&e? . rare *ut potentially fatal syndrome occurring in the conte)t of initiation of serotonergic agent! characterised *y altered mental state! agitation! tremor! shi(ering! diarrhoea! hyperrefle)ia! myoclonus and hyperthermia. <= of patients on SSR, Pathophysiology$ due to increase in serotonin. " inica !eatures? (utono&ic? hyperthermia! nausea! diarrhoea! mydriasis! tachycardia! hyper3hypotension Neuro&uscu ar? myoclonus! rigidity and tremors! hyperrefle)ia! ata)ia ore rapid onset! rapid progression and less rigid than N S. In/estigations? same as N S! add in 9SR to rule out aspiration! #9E to loo/ for prolonged J&c Treat&ent? - 9onsult medical! it is a medical emergency.
- ,C access! to allo' (olume correction to reduce the ris/ of rha*domyolysis - Prescri*e *en0odia0epine to control agitation! sei0ure and muscle rigidity. "ourse and 'rognosis? - Resol(e 'ith 2? 7 :; hours - ortality T < in <000 "ha'ter #0 S ee' disorders #0.# Nor&a s ee' B stages and cyc e - . typical night+s sleep has ? or > cycles of stages! each lasting L0 7 <<0 minutes. - .s night progresses! the amount of time spent in delta sleep decreases 'ith conse2uent increase in R# sleep. - &otal sleep time in adult is *et'een > 7 L hours. Stage < Stage 2 Stage : 5 ? R# @ight sleep! 'ith slo' theta and delta 'a(es W comple)es Delta 'a(e! slo' 'a(e sleep @o' (oltage! desynchronised ##E acti(ity
(ssess&ent o! s ee' disorders? Present 6nset! duration! course! compliant fre2uency! stressors Daily routine 8a/ing! daily acti(ities! *ed time Description Aeha(iour during sleep! of sleep dream! 'a/ening! satisfaction Daytime @e(el of alertness! effect on somnolence 'or/! Drug 5 Regular hypnotics alcohol 9affeine containing drugs #0.$ Inso&nia ,nsomnia in(ol(es difficulty to fall asleep! maintaining sleep and poor 2uality of sleep as persistent pro*lem : days per 'ee/ for one month. 7'ide&io ogy - 9ommon pro*lem - DM - Ereater in elderly - 9hronic significant insomnia 7 ;= (etio ogies? Intrinsic causes?
24
Dr. Roger Ho
Psychophysiological insomnia associated 'ith an)iety Sleep state misperception (constant monitoring of sleep) ,diopathic insomnia Sleep apnoea syndrome Periodic lim* mo(ement disorder
74trinsic causes? - ,nade2uate sleep hygiene - Dependency related sleep disorder li/e hypnotics - Nocturnal eating and drin/ing Medica and Psychiatric causes? - Pain - Respiratory (96PD) - Par/inson disease - #ndocrine$ .ddison! 9ushing - Depression! *ipolar disorder - .n)iety disorder! P&SD - Schi0ophrenia Manage&ent? - .ddress underlying pro*lem (drug dependency) - 7ducation? stages and cycles. - S ee' hygiene &easures? Eood sleep ha*its and stimulus control - Re a4ation training - "se of hypnotics if unresponsi(e to a*o(e 6ength o! action "ltra 7short 2 hr <0mg 6N H<.80 74a&' es 1olpidem (Stilno)) "o&&ents Non 7 A1D Dacilitate onset of sleep .lso has potential of dependency! cause re*ound insomnia ,nitiating! maintaining! 9onsolidating sleep Non A1D Aitter taste ,nitiating! maintaining! 9onsolidating sleep
Hang o(er effect on the morning Mida*o a& (Dor&icu&) has (ery fast onset of action and high potency! it has high potential for dependency. ,t is not recommended for regular oral usage. "h. $2 "hi d Psychiatry $2.# (ttention De!icit % Hy'er:inetic Disorder ((DHD) .DHD is a persistent pattern of inattention B3- hyperacti(ity that is de(elopmentally inappropriate. &he symptoms should ha(e an onset in childhood. 7'ide&io ogy? - "S.$ :->= (o(er-diagnosis) - "W$ <= $D N :$< (etio ogy? <enetics? - >0= ris/ in 1 t'ins! 2) increase in si*lings - Eenes$ >! ;! << are implicated. - Neuroimaging$ frontal hypometa*olism - Dopamine 5 >H& dysregulation in prefrontal corte) " inica !eatures? Hy'eracti/ity sy&'to&s Didgeting! mo(ing! getting up 5 do'n! clim*ing on des/s Alurting out ans'ers! [umping the 2ueue Inattention sy&'to&s 9annot sustain attention Poor tas/ completion a/ing mista/es 'hen tas/ re2uire attention
Dalmadorm N"H only <>-:0mg
,ntermediate ; hours
@ora0epam .ti(an <mg 6N 1opiclone ,mo(ane I.>mg 6N Dia0epam Calium >-<0mg Dlura0epam
(ssess&ent? - ,nter(ie' 'ith parents$ de(elopmental history - 6*ser(e attachment style and le(el of acti(ity of child - 9ollateral info from school Treat&ent? - 9A&$ *eha(ioural techni2ues - Social s/ill training - Parent management training - #ducation and remedial inter(ention - Stimulant$ ethylpenidate >-<0mg 6 $ increase Dopamine 5
@ong acting M <2 hours
25
Dr. Roger Ho
noradrenaline 'hich can increase concentration 5 attention! side effect include gro'th retardation 'hich re2uires drug holiday. 1utco&e - 20= de(elop antisocial personality disorder - 20= de(elop su*stance a*use disorder $2.$ "onduct disorder . repetiti(e and persistent pattern of *eha(iour in 'hich the *asic rights of others or maFor age appropriate societal norms are (iolated. 7'ide&io ogy - #arlier onset and is more common in *oys than in girls. (etio ogy Bio ogica !actors - Damily history of antisocial *eha(iour or su*stance a*use. - @o' 9SD serotonin - @o' ,J - Arain inFury Psychosocia - Parental criminality - Su*stance a*use in parents - Harsh and inconsistent parenting - Domestic chaos and (iolence - @arge family si0e - @o' socioeconomic status and po(erty - #arly loss and depri(ation > School failure
9D is often chronic and unnamea*le. .ntisocial PD in adults T>0=
Poor outco&e? #arly onset T <0 year old! lo' ,J! poor school achie(ement! attentional pro*lems! hyperacti(ity! family criminality! poor parenting. $2.) (utis&
It is characterised by the triad o! sy&'to&s? - .*normal social relatedness - . 2ualitati(e a*normality in communication and play - Restricted! repetiti(e and stereotyped *eha(iour! interests and acti(ities 7'ide&io ogy? - 6nset is typically *efore age :. $D N :-?$< - Pre(alence$ >-<03<000 (etio ogy? - Eenetic - 6*stetric complications - &o)ic agents - Pre3postnatal infections. - .ssociation 'ith tu*erous sclerosis Patho'hysio ogy MRI? - ,ncrease in *rain si0e - ,ncrease in lateral and ?th (entricle - Drontal 5 cere*ellar a*normalities - .*normal pur/inFe cells in cere*ellar (ermis. - .*normal lim*ic architecture. " inica !eatures? - (bnor&a socia re atedness$ poor eye contact and no peer relationship - (bnor&a co&&unicationC' ay? lac/ of language! difficulty to initiate con(ersation. - Restricted interests or acti/ities? non functional routines or rituals (*us schedule) - Neuro ogica ? tics! increase in head circumference! a*normal ga0e - Physio ogica ? a*normal response to pain! a*normal temperature regulation.
" inica -
!eatures? .ggression 9ruelty to people and animals Destruction of property Deceitfulness or theft Serious (iolation of rules Eang in(ol(ement @ac/ of empathy
Manage&ent? - #nsure the safety of the child - 9A& pro*lem sol(ing s/ill - Parent management training - Damily therapy - .cademic 5 social support referral "ourse and outco&e?
26
Dr. Roger Ho
Beha/ioura ? irrita*ility! temper tantrums! self 7 inFury! hyperacti(ity! aggression
(ssess&ent? - Re2uires ultidisciplinary approach - Rating scale$ .utism Aeha(ioural 9hec/list
Aegin 'ith su*Fects 'ell a'ay from the presenting pro*lem (interests! ho**ies! friends and si*lings! school and holidays) Progress to en2uire a*out the child+s (ie' of the pro*lems 6*ser(e the le(el of acti(ities and attention during the inter(ie' &ry to inter(ie' the child and family together to o*ser(e family dynamics Schoo re!usa
Treat&ent? - 7ducation % /ocationa inter/entions - Beha/ioura inter/entions - Fa&i y inter/entions - S'eech and anguage thera'y $2.+ (s'erger Syndro&e ((S)
$2.,
7'ide&io ogy pre(alence of <-2 = slightly more common in *oys more common during three periods in school life$ <. age > (starting school) 2. I years (change to Funior school) :. << years (starting secondary school) ?. <? years and older! 'hen there is often associated depression and difficulties in school
Se(ere persistent impairment in social interactions! repetiti(e *eha(ioural patterns and restricted interests. ,J and language are normal or superior. ild motor clumsiness and family history of autism may *e present. Ne'ton and #instein may ha(e .S 7'ide&io ogy ale predominance - < in :00 " inica !eatures - Narro' interests and preoccupation of a su*Fect - Repetiti(e *eha(iours or rituals - Peculiarities in speech and language - #)tensi(e logical or technical patterns of thought - Socially and emotionally inappropriate *eha(iour and interpersonal interaction - Pro*lems 'ith non (er*al communication - 9lumsy and uncoordinated motor mo(ements. $2.(''roaches to the "hi d #sta*lish the rapport and gaining the child+s confidence
(etio ogy associated 'ith se+arat!on anx!ety especially in younger children may occur after a minor life e(ent$ illness some older children ha(e depression increased incidence of an)ious! o(erprotecti(e mother in com*ination 'ith a 'ea/! passi(e! ineffectual! or a*sent father children are often emotionally immature and ha(e not learned to accept frustration
" inica !eatures there are often somatic symptoms such as headache! a*dominal pain! diarrhoea! sic/ness! or (ague complaints of feeling ill 7 these complaints occur on school days *ut not at other times the final refusal may occur after se(eral e(ents$ follo'ing a period of increasing difficulty after an enforced a*sence such as respiratory infection
27
Dr. Roger Ho
after an e(ent at school such as change of class follo'ing a pro*lem in the family such as illness of another family mem*er
6nset$ I years old $D N :$< Pre(alence$ >3<0!000 Eenetics factors$ .D ,n(ol(es dopamine system and Aasal Eanaglia 9omor*idity$ depression! 69D &reatment$ Haloperidol <.>mg->mg! 9A& Re!? 14!ord Handboo:5 $22+ $# 6earning Disabi ityC Menta Retardation $#.# IG and earning disabi ity (6D) 6D Mi d Moderate Se/ere Pro!ound IG -2>,0 )->+0 $2>)+ Be o8 $2 Features ,ndependent self care Some deficit in language! simple 'or/ @o'er le(el of 'or/! motor impairment Cery limited language 5 *asic s/ills
Treat&ent an early return to school is important discussion 'ith teachers is needed depressi(e disorder should *e treated
Prognosis 'orse prognosis in older children higher incidence of psychiatric disorders (e.g. agorapho*ia) in adult life
$2. . 7nuresis Coluntary3in(oluntary (oiding of urine at night for child M > yr old. I>= ha(e family history of enuresis &o rule out "&,! neurological pro*lems! o*structi(e uropathy. Pri&ary enuresis$ ne(er dry Secondary enuresis$ pre(iously dry Aeha(ioural modification is important treatment$ starchart to re'ard patient! restrict fluid at night edication$ imipramine (&9.) $2.3 "onse=uence o! chi d abuse? - P&SD - Dissociati(e disorder - 9on(ersion disorder - Aorderline personality disorder - Depression - Paraphilias - Su*stance a*use $2.0 TouretteMs syndro&e
$#.$ Do8n Syndro&e ost common genetic cause of @D &risomy of chromosome 2< ,J most often *elo' >0 De(elop .l0heimer+s disease at ?0s and >0s " inica !eatures o! Do8n syndro&e
ultiple motor and (ocal tics for a year! 'ith distress and impairment function. Facia tics as initial symptoms Voca tics? meaningless sounds to clear 'ords and coprolalia &ic 'a) and 'ane! e)acer*ations due to stress
28
Dr. Roger Ho
Lesley Stevens, Ian Robin, Psychiat y ! "n ill#st ate$ colo# te%t, &h# chill livin'stone 2001 $#.) Foeta ( coho Syndro&e - aFor causes of learning disa*ility > 0.2 7 : per <000 li(e *irths - 9aused *y maternal alcohol use. Due to effect of alcohol on N D. receptors 'hich affects cell proliferation " inica !eatures? ( coho 8ithdra8a $ irrita*ility! hypotonia! tremor and sei0ures Facia !eatures? icrocephaly! small eye fissures! epicanthic folds! short palpe*ral fiussure! small ma)illae and mandi*les! cleft palate! thin upper lip <ro8th de!icits? Small o(erall length! Foint deformities. "NS? *eha(iour pro*lems$ hyperacti(e! sleep pro*lems! poor (isual acuity! hearing loss! language deficits. 1ther? .SD! CSD! renal hypoplasia.
$$ $$.#
6ega % 7thica (s'ects Menta Disorder and Treat&ent (ct
- 9an only apply at , H (8ood*ridge hospital) in Singapore "riteria !or co&'u sory ad&ission at IMH 1) &he person suffers from a mental disorder of a nature or degree 'hich ma/es it appropriate for the person to recei(e psychiatric treatment in , H. 2) .dmission is li/ely to alle(iate or pre(ent deterioration in a psychiatric condition (Schi0ophrenia! Aipolar disorder) 3) ,t is necessary for the health or safety of the patient or for the protection of other persons that the person should recei(e such treatment and it cannot *e pro(ided unless he is compulsory admitted. 74a&' e? .ssume you are the .#D medical officer 'or/ing in a general hospital. . 2L year old male suffers from paranoid schi0ophrenia
29
Dr. Roger Ho
'as *rought in to your .#D. He has *een (iolent at home and attac/s his parents. He has poor insight and has defaulted his treatment for : months. He refuses to *e admitted to your general hospital psychiatric unit (or your psychiatric 'ard is full) ,n this case! you can send the patient to , H for assessment. (Uou need to call the , H registrar on call at ;:8L 2000) &he , H medical officer or registrar 'ill sign the Dorm < of ental Disorder and &reatment .ct$ compulsory admission for I2 hours. $$.$ Dri/ing and Psychiatric i ness (Based on IK a85 Singa'ore does not ha/e c ear guide ine on this) For schi*o'hrenia5 bi'o ar disorder? Dri(ing must cease during acute illness Re-licensing for pri(ate car$ - has remained 'ell and sta*le for at least : months - 9ompliant 'ith treatment - Dree from ad(erse effects of medication - Regain of insight Dor professional dri(er$ *us dri(er! ta)i dri(er or lorry dri(er$ Re-licensing may *e possi*le if 'ell and sta*le for a minimum of : years 'ith minimum dosage of medication and no significant li/elihood of recurrence De&entia? &hose 'ith poor short term memory! disorientation! lac/ of insight and Fudgement are not fit to dri(e. $$.) Dia ysis and Schi*o'hrenia 6ou ha$e a 2' year old lady suffer!n" from chron!c sch!7o+hren!a and end sta"e renal fa!lure. She ants to sto+ d!alys!s. The renal team !s $ery concerned as she may d!e and they ant to see) your o+!n!on. Suffering from schi0ophrenia does not mean the patient has no capacity to decide on her dialysis.
Dirst! 'e ha(e to determine 'hether the patient has the capacity to ma/e the decision to 'ithhold dialysis. ,n order to sho' that she has the capacity! she must *e a*le to understand and *elie(e that she suffers from end stage renal failure4 dialysis is used to treat #SRD and she 'ill die if she stops dialysis. 8e need to consider the follo'ing$ ,t is good to e)plore the psychological aspects of dialysis$ se)ual dysfunction is common4 they are more isolated and costs of dialysis may reduce their 2uality of life and anaemic can cause fatigue. "raemia can lead to impaired mentation! lethargy! multifocal myoclonus. Dialysis can lead to neuropsychiatric symptoms such as dialysis dementia! delirium and depression. 8e may need to treat patient+s neuropsychiatric symptoms *y antidepressant or antipsychotics and reassess her capacity later. $) Psychothera'y "o&&on 'sychothera'ies 'ractised in Singa'ore inc ude? $).# Su''orti/e Psychothera'y .ims to offer practical and emotional support! opportunity for (entilation of emotions! and guided! pro*lem sol(ing discussion. #)amples include counselling and general psychiatric follo' 7 up. $).$ Brie! 'sychodyna&ic 'sychothera'y ,t is an acti(e therapy 'here the therapist attempts to guide free association on more focused topics. Rationa e? - Shorter time scale of long term psychoanalysis (too e)pensi(e and difficult for patient to stay in therapy for so long) Indication? - ,ndi(iduals 'ith emotional pro*lems in psychological terms. - Docal conflicts -
30
Dr. Roger Ho
Techni=ues? - <oa setting$ tac/le an)iety3 defence - Focus choosing? repetiti(e *eha(iour to a single transference figure - (cti/e inter'retation Trans!erence Patient+s feeling to'ards therapist "ountertrans!erence &herapist+s feeling to'ards patient
/e Identi!ic ation
Phases o! treat&ent - Initia ? setting treatment contract! formulation of the case - 7ar y session$ ,dentify central issue - Midd e session? e)plore transference - " osing$ anticipate termination! arrangement of aftercare. $).) "BT Aeha(iours and emotions are determined *y person+s cognitions. Some pathological emotions are as a result of cogniti(e errors. ,f the person can *e helped to understand the connection *et'een cogniti(e errors and distressing emotion! they can try methods to change. &he therapist aims to assist the patient to monitor cognitions! identify cogniti(e errors! understand maladapti(e schema! e)plore 'ith strategies and challenge and e)amine the resultant effects. Beha/ioura techni=ues .cti(ity scheduling Eraded assignment #)posure3 response pre(ention Rela)ation training "ogniti/e techni=ues Psychoeducation ,dentify automatic thoughts Role play &houghts diary #)amine e(idence
Reactio n !or&ati on Dis' ac e&ent
Rationa isation Sub i&a tion
*elief or emotion to a second person. &hen! there is another action in 'hich the second person is changed *y the proFection and *egins to *eha(e as though he or she is in fact actually characteri0ed *y those thoughts or *eliefs that ha(e *een proFected. &he e)pression e)ternally of attitudes and *eha(iours 'hich are the opposite of the unaccepta*le internal impulses. &ransferring the emotional response to a particular person! e(ent! or situation to another 'here it does+t *elong *ut carries less emotional ris/. [ustifying *eha(iour or feelings 'ith a plausi*le e)planation after the e(ent! rather than e)amining unaccepta*le e)planation. Regarded as healthy defence mechanism! &he e)ternal e)pression of unaccepta*le internal impulse in socially accepta*le 'ay. < ossary
"h. $+
( e4ithy&ia? &he ina*ility to descri*e one+s su*Fecti(e emotional e)periences (er*ally. (&nesia (nterograde? the period of amnesia *et'een an e(ent and the resumption of continuous memory. &he length of anterograde amnesia is correlated 'ith the e)tent of *rain inFury. Retrograde? &he period of amnesia *et'een an e(ent and the last continuous memory *efore the e(ent. (utochthonous de usion? . primary delusion 'hich appears to arise fully formed in the patient+s mind 'ithout e)planation. (utosco'y? (Phantom irror image) &he e)perience of seeing a (isual hallucination or pseudohallucination of oneself. "on!abu ation? &he process of descri*ing plausi*ly false memories for a period for the patient has amnesia. 6ccurs in Worsa/off psychosis! dementia.
De!ence &echanis&s Re'ress "nconscious forgetting of pain ion memory and impulse. Regress Re(ert to functioning of a ion pre(ious maturational point. Denia Refusal to consciously ac/no'ledge e(ents or truths 'hich are o*(ious. ProJecti .ttri*uting one+s o'n on unaccepta*le ideas or impulses to another person. ProJecti 6ne person proFects a thought!
31
Dr. Roger Ho
"o'ro a ia? . forced (ocalisation of o*scene 'ords or phrases. &he symptoms is largely in(oluntary *ut can *e resisted for a time! at the e)pense of mounting an)iety. 6ccurs in &ic disorder "ou/ade syndro&e? . con(ersion symptom seen in partners of e)pectant mothers during their pregnancy. DRJS /u . sense that e(ents *eing e)perienced for the first time ha(e *een e)perienced *efore. .n e(eryday e)perience *ut also a non specific symptoms of a num*er of disorders including temporal lo*e epilepsy! schi0ophrenia and an)iety disorders. ,n contrast! Ta&is Vu is the sensation that e(ents or situations are unfamiliar! although they ha(e *een e)perienced *efore. De usiona &e&ory . primary delusion 'hich is recalled as arising as a result of a memory (eg patient 'ho remem*ers his parents ta/ing him to hospital for an operation as a child *ecoming con(inced that he had *een implanted 'ith monitoring de(ices 'hich ha(e *ecome acti(e in his adult life) De usiona &ood? . primary delusion 'hich is recalled as arising follo'ing a period 'hen there is an a*normal mood state characterised *y anticipatory an)iety! a sense of something a*out to happen and an increased sense of significance of minor e(ents. De usiona 'erce'tion? . primary delusion 'hich is recalled as ha(ing arisen as a result of perception. &he percept is a real e)ternal o*Fect. De usion o! gui t? . delusional *elief that one has committed a crime or other reprehensi*le act. ,t is a feature of psychotic depressi(e illness. De usion o! in!estation (7:bo& syndro&e)? . delusional *elief that one+s s/in is infested *y multiple! tiny! mite li/e animals. De usion o! re!erence? . delusional *elief that e)ternal e(ents or situations ha(e *een
arranged in such a 'ay as to ha(e particular significance for or to con(ey a message to the affected indi(idual. De'ersona isation? .n unpleasant su*Fecti(e e)perience 'here the patient feels as if they ha(e *ecome unreal. Derai &ent (KnightMs &o/e thin:ing)? schi0ophrenic thought disorder in 'hich there is total *rea/ in the chain of association *et'een the meaning of thoughts. Derea isation$ .n unpleasant su*Fecti(e e)perience 'here the patient feels as if the 'orld has *ecome unreal. Digenes syndro&e$ Hoarding of o*Fects! usually of no practical use and neglect of one+s home and en(ironment. Due to organic disorder! schi0ophrenia! 69D. Dysarthria Dys e4ia Dys'hasia ,mpairment in a*ility to properly articulate speech ,na*ility to read at the le(el normal for one+s age or intelligence ,mpairment in producing or understanding speech (e)pressi(e dysphasia Arocas and recepti(e dysphasia - 8ernic/e) related to cortical a*normality .n emotional state e)perienced as unpleasant! secondary to depression ,na*ility to carry out comple) motor tas/s (dressing! eating)
Dys'horia Dys'ra4ia
7dietic i&agery$ Particular type of e)ceptionally (i(id (isual memory. Not a hallucination. ore common in children. 74traca&'ine ha ucination . hallucination 'here the percept appears to come from *eyond the area usually co(ered *y he senses (eg a patient in 9lementi hearing (oices seeming to come from a house in 9hangi) <anser sy&'to&s$&he production of appro)imate ans'ers. Here the patient gi(es repeated 'rong ans'ers to 2uestions 'hich
32
Dr. Roger Ho
are nonetheless in the right *allpar/. 8hat is 2B2O N >. ore common in alingering. < obus Hytericus? &he sensation of a lump in the throat occurring 'ithout oesophageal structural a*normality. Hy'nagogic ha ucination? . transient false perception e)perienced 'hile on the (erge of falling asleep Hy'no'o&'ic ha ucination? &he same phenomenon e)perienced 'hile 'a/ing up I usion? . false type of false perception in 'hich the perception of a real 'orld o*Fect is com*ined 'ith internal imagery to produce a false internal percept. 6i i'utian ha ucination? . type of (isual hallucination in 'hich the su*Fect sees miniature people or animals. .ssociated 'ith organic state li/e delirium tremens. 6oosening o! associations$ @ac/ of meaningful connection *et'een se2uential ideas. Magica thin:ing? . *elief that certain actions and outcomes are connected although there is no rational *asis for esta*lishing a connection. Ma ingering? Deli*erately falsifying the symptoms of illness for a secondary gain. Mirror sign? @ac/ of recognition of one+s o'n mirror reflection 'ith the perception that the reflection is another indi(idual 'ho is mimic/ing your actions.
1/er/a ued idea? . form of a*normal *elief. &hese are ideas 'hich are reasona*le and understanda*le in themsel(es *ut 'hich come to unreasona*ly dominate the patient+s life. Preser/ation? 9ontinuing 'ith a (er*al response or action 'hich 'as initially appropriate after it ceases to *e apposite. Do you /no' 'here you areO ,n the hospitalO Do you /no' 'hat day is itO ,n the hospital. Russe Sign$ s/in a*rasions! small lacerations and the calluses on the dorsum of the hand o(erlying the metacarpophalangeal and interphalangeal Foints found in patients 'ith symptoms of *ulimia. 9aused *y repeated contact *et'een incisors and the s/in of the hand 'hich occurs during self induced (omiting. Synaethesia? . stimulus in one sensory modality is percei(ed in a fashion characteristic of an e)perience in another sensory modality (tasting sounds). Tangentia ity? Producing ans'ers 'hich are only (ery indirectly related to the 2uestion as/ed *y the e)aminer. Trichoti o&ania? 9ompulsion to pull one+s hair out. Re!erences? <) @e(i. Aasic Notes in Psychiatry. Radcliffe Pu*lishing @td <LL8. 2) D. Semple! R. Smith! [ Aurns! R. DarFee! .. clntosh. 6)ford Hand*oo/ of Psychiatry. 6)ford "ni(ersity Press. 200? :) '''.tric/cyclists.co.u/
Appendix
Appendix 3a Neurodevelopmental Hypothesis of Schizophrenia
33
Dr. Roger Ho
&here is an e4cess o! obstetric co&' ications in those 'ho de(elop the disorder. .ffected su*Fects ha(e &otor % cogniti/e 'rob e&s 'hich precede the onset of illness. Schi0ophrenia su*Fects ha(e abnor&a ities o! cerebra structure of <st presentation. .lthough the *rain is a*normal! g iosis is absent 7 suggesting that differences are possi*ility ac2uired in utero.
* o+, -o# .#estions ans/e e$ se ies ! Schi0o)h enia, &h# chill Livin'stone
Appendix 3b Brain abnormalities of Schizophrenia
Lesley Stevens, Ian Ro$in ! Psychiat y an ill#st ate$ te%t, &h# chill Livin'stone( 2001
"))en$i% 3&
34
Dr. Roger Ho
Lesley Stevens, Ian Robin, Psychiat y ! "n ill#st ate$ colo# te%t, &h# chill livin'stone 2001 Appendix 5a - oxic effect of lithium
Lesley Stevens, Ian Robin, Psychiat y ! "n ill#st ate$ colo# te%t, &h# chill livin'stone 2001 Appendix !a " S# and $rief
35
Dr. Roger Ho
Lesley Stevens, Ian Robin, Psychiat y ! "n ill#st ate$ colo# te%t, &h# chill livin'stone 2001 "))en$i% 10
Lesley Stevens, Ian Robin, Psychiat y ! "n ill#st ate$ colo# te%t, &h# chill livin'stone 2001
36
Dr. Roger Ho
Appendix %&a
Lesley Stevens, Ian Robin, Psychiat y ! "n ill#st ate$ colo# te%t, &h# chill livin'stone 2001
Mne&onics in Psychiatry (Mne&onics !or MR"P5 P(ST7ST5 $22,)
37
Dr. Roger Ho
Disorder Negati(e symptoms of schi0ophrenia Depression
Mne&onic >.s and P@.N&
D#PR#SS,6N
.N,.
.N,.9
#ating disorder
R.P,D
Worsa/off psychosis
.DD,9&
#ating disorder
,ncreases in the follo'ing
Brea:do8n o! Mn&onic aPathy a@ogia aDfecti(e flattening aNhedonia a&tentional deficit Depressed mood #nergy loss Pleasure loss Retardation$ psychomotor #ating change Sleep distur*ance Suicidal ideation , am a failure 6nly me to *lame N guilt No concentration ood increase .cti(ity 3 energy increase No inhi*ition ,nsomnia .l'ays thin/ing M Pressure of speech! flight of ideas 9onfidence e)cess grandiose Refusal to maintain 'eight .menorrhoea Preoccupation 'ith food and 'eight ,nduction of diarrhoea and (omiting Distur*ance in the 'ay 'eight and si0e are percei(ed .mnesia Disorientation ,nsight loss 9onfa*ulation &hiamine deficiencies Nuclei .cid *ases$ E 7 Ero'th hormone 9 7 cortisol and cholesterol . 7 .mylase & 7 &ransaminase " 7 "rea and 9reatinine #(erything else decreases
38

Lecture Notes On Psychiatry

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Lecture Notes On Psychiatry

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Study Notes in Psychiatry (2008)

Study Notes in Psychiatry (For MBBS III to V)

Study Notes in Psychiatry (2008)

Study Notes in Psychiatry (2008)

Study Notes in Psychiatry (2008)

Study Notes in Psychiatry (2008)

$-H Partial reco(ery

$-H Do'nhill course

Study Notes in Psychiatry (2008)

Study Notes in Psychiatry (2008)

Study Notes in Psychiatry (2008)

Study Notes in Psychiatry (2008)

"h. , De'ressi/e Disorder

Study Notes in Psychiatry (2008)

Study Notes in Psychiatry (2008)

6rganic disorders Depressi(e disorders

(n4iety Disorders (14 handboo:)

Study Notes in Psychiatry (2008)

Study Notes in Psychiatry (2008)

Study Notes in Psychiatry (2008)

Study Notes in Psychiatry (2008)

"hronic e!!ects 9hronic amoti(ational syndrome. Dlash*ac/ phenomena Psychotic reactions

Study Notes in Psychiatry (2008)

Study Notes in Psychiatry (2008)

Study Notes in Psychiatry (2008)

"h. #+ Perinata Psychiatry #+.# Baby b ues

Study Notes in Psychiatry (2008)

Ref$ 6)ford Hand*oo/! 200?

Study Notes in Psychiatry (2008)

Study Notes in Psychiatry (2008)

Study Notes in Psychiatry (2008)

Study Notes in Psychiatry (2008)

Harsh and inconsistent parenting 9onduct disorder in childhood

Study Notes in Psychiatry (2008)

Study Notes in Psychiatry (2008)

Dalmadorm N"H only <>-:0mg

@ong acting M <2 hours

Study Notes in Psychiatry (2008)

9D is often chronic and unnamea*le. .ntisocial PD in adults T>0=

Study Notes in Psychiatry (2008)

Beha/ioura ? irrita*ility! temper tantrums! self 7 inFury! hyperacti(ity! aggression

(ssess&ent? - Re2uires ultidisciplinary approach - Rating scale$ .utism Aeha(ioural 9hec/list

Study Notes in Psychiatry (2008)

Study Notes in Psychiatry (2008)

6ega % 7thica (s'ects Menta Disorder and Treat&ent (ct

Study Notes in Psychiatry (2008)

Study Notes in Psychiatry (2008)

Reactio n !or&ati on Dis' ac e&ent

Rationa isation Sub i&a tion

Study Notes in Psychiatry (2008)

Study Notes in Psychiatry (2008)

Study Notes in Psychiatry (2008)

Appendix 3b Brain abnormalities of Schizophrenia

Study Notes in Psychiatry (2008)

Study Notes in Psychiatry (2008)

Study Notes in Psychiatry (2008)

Mne&onics in Psychiatry (Mne&onics !or MR"P5 P(ST7ST5 $22,)

Study Notes in Psychiatry (2008)

Disorder Negati(e symptoms of schi0ophrenia Depression

Mne&onic >.s and P@.N&

,ncreases in the follo'ing

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