PSYCHIATRY

Ida

Content

Title

Page Number

Psychiatric Evaluation

Liaison Psychiatry

Personality Disorders

14

Stress Disorders

16

Childhood Disorders

18

Eating Disorders

23

Substance Abuse

26

Schizophrenia, Depression and Bipolar Mood Disorder

36

Suicide and Deliberate Self-harm

42

Anxiety Disorders

45

Pregnancy-related Depression

49

Cognitive Disorders

50

Psychotropic treatment

59

EPS and NMS

67

Malaysian Psychiatry

69

Note: This book follows the diagnostic criteria from DSM-IV-TR

Psychiatric evaluation

Perpetuating factor

Knowing the patient

Predisposing factor

why did the patient develop this disorder?

significant family history
personality disorder or traits
traumatic childhood experiences
chronic stress
substance use

what are the factors that may prevent him from

getting better?
poor social support
poor pre-morbid level of functioning
poor insight
late treatment
co-morbid substance use
criminal record
unemployment

Mental State Examination

Precipitating factor

why develop at this point in time?

Protective factor

what are the factors that will help him recover?

good social support
good pre-morbid level of functioning
good insight
early intervention
no substance use including alcohol
no criminal behaviour

Appearance and behaviour

Abnormal behaviour
Built
Cleanliness, consciousness, cooperation
Distractibility, dressing
Eye contact
Facial expressions

Speech

Language spoken
Adequate
Coherent
Relevant
Comprehension of speech

Mood and Affect

Current mood
Labile mood
Congruent affect

Thought content

Delusions
Obsessions
Concerns
Suicidal thoughts
Depressive thoughts
Phobias

Perception

Hallucinations
Illusions

Abstract reasoning and concrete thinking: explain a

proverb, similarities between table and chair
General knowledge: capital city of Malaysia,
Independence Day
Judgment: in a burning house, burglar in the house
Insight: awareness, attribution and acceptance of
condition

Physical examination
- to rule out medical causes for the symptoms
- to check for side effects from psychiatric medications
- to look for co-morbid medical disorders

Multiaxial diagnosis
Axis I: Psychiatric disorder
Axis II: Developmental or personality disorder

Cognitive functions

orientation to time, place and person

memory: immediate (immediate recall of 5 objects),
recent (recall the 5 objects after 5 minutes, events
that happened last 24 hours), remote (IC number,
address)
Attention and concentration: serial 7, WORLD
backwards

Axis III: General Medical condition

Axis IV: Presence of ongoing psychosocial stressors
Axis V: Global Assessment of Functioning

Liaison psychiatry
Classification of psychiatric illness encountered in
liaison setting
- Psychiatry provoking ill-health
- Psychiatry as consequence of organic disease
- psychiatric symptoms as presenting symptoms
- cerebral complications of organic disease
- abuse of alcohol and drugs
- deliberate self-harm
- sexual/relationship problems and eating disorders
- psychiatric disorder exacerbate physical illness
- physical symptoms without organic basis
- psychiatric and physical illness occurring by chance

Liaison case summaries

- reason for referral
- psychiatric diagnosis
- physical disease and patient's reaction to it
- evidence of abnormal illness behaviour
- relationship between the psychological and physical
aspects of the case
4

- patient's personality coping strategies

- patient's attitude towards psychiatric intervention
- staff attitude towards patient

Psychiatric disorder in physical illness

Factors affecting prevalence of psychiatric disorder in
physical illness
Illness

symptoms
threat to life
course (acute, relapsing, chronic)
duration
disability
conspicuousness

Treatment

nature
side-effects
uncertainty of outcome
need for self-care

Patient

psychological vulnerability
social circumstances
other stresses (chronic and acute)
reactions of others

Factors associated with a particularly high risk of

psychiatric problems
Severe illness

unpleasant
threatening
acute relapsing or progressive illness

Unpleasant treatment

major surgery
radiotherapy
chemotherapy

Vulnerable patients

history of previous psychiatric problems

current psychiatric disorder
adverse social circumstances
lack of personal and emotional support

Implications for assessment

Characteristics of "at-risk" patients
5

systematic review of patients, looking for psychiatric

problems
presence of key symptoms
information from relatives
implications for treatment

- describes the actions of the patient and his attitude

towards medical personnel
- eg stoical, restrained, histrionic, dramatizing, hostile,
suspicious, flirtatious, pleading, aloof, excessively
cooperative and agreeable

Affective disorder

Abnormal illness behaviour

- worsens prognosis of stroke and MI

- uncomfortable awareness of bodily events much of the

time together with excessive fears and concerns about
health and disease

Positive psychological changes

- enhanced appreciation of life
- less concern for trivial or material things
- more tolerance towards others
- improved self-worth

- relentless search for causes and cures coupled with

inability to accept reassurance from doctors even when this
has been given clearly plus appropriate investigation done
- inability to accept the suggestion that non-physical
factors may be relevant to one's condition
- disability out of proportion to detectable organic disease

Sick role
- sick individual is obliged to seek the appropriate help,
cooperate with assessment, accept a diagnosis and comply
with the treatment
- legitimate adoption of this role requires sanction from
relatives, medical practitioners, employers and others in
authority

- reinforcement of illness behaviour by family, disability

payments and health care providers
- inappropriate response to physical disorder - either
excessive disability or denial of need of
treatment/limitation of activities
- adoption of lifestyle around the sick role with repertoire of
behaviours to sustain sick role

Illness behaviour
6

Depression
Risk factors for depressive disorders in physical illness

Possible mechanism of co-morbidity

- female gender

- effect on immune system

- being unmarried

- side effects of medications

- living alone

- physical sequelae of suicide attempts

- previous depressive episodes

- possible common genetic predisposition

- effect on neurotransmitters

- certain medical treatments

- severe forms of physical illness

Post-stroke depression

Depression in physically ill

- up to 50% of patients develop post-stroke depression in

acute post-stroke period

- co-morbid disorders continue after discharge

- often goes undetected

Risk factors for post-stroke depression

- depressive disorders co-occurring with physical illness

complicate treatment of both disorders

- left anterior brain lesions (especially caudate nucleus)

- predicts readmission

- living alone

- postponing treatment of depressive disorder worsens

prognosis of both

- past history of major depressive episodes

- high healthcare costs

- previous history of pyschiatric and/or cerebrovascular

disorder

- poor quality of life

- family history of mood disorders

- dysphasia

Anxiety
- causes increased vulnerability to cardiac events
- phobic anxiety and generalised anxiety are predictors of
MI and cardiac death

Medications that cause anxiety-like symptoms

Stimulant intoxication: caffeine, nicotine, cocaine,

metamphetamines, phencyclidine

Sympathomimetics: pseudoephedrine,
methylphenidate, amphetamines, beta agonists

- perpetuates the disability

Dopaminergics: amantadine, bromocriptine,

levodopa

Organic anxiety syndromes

Anticholinergics: benztropine, diphenhydramine,

meperidine

- cardiovascular system: angina, arrhythmia, congestive

cardiac failure

- endocrine system: hyperthyroidism, phaeochromocytoma,

menopause

Miscellaneous: ephedrine, indomethacine,

steroids

Drug withdrawal: alcohol, BDZ, opiates

Anticipatory anxiety

- metabolic disorders: hypoglycemia, hypoxia

- neurologic disorders: seizure disorder, akathisia
- gastrointestinal system: peptic ulcer disease

Cancer

- respiratory system: asthma, COPD

- psychological impact of diagnosis depends on the way the

disease presents

- immunologic disorder: anaphylaxis, SLE

- impact is greater if cancer is detected unexpectedly in an

apparently healthy person
- uncertainty when patient first comes to clinic may be so
stressful that they develop anxiety while waiting for the
investigation results

- vulnerable personality - poor coping with stress

- direct effects of illness to the brain
- side effects of drugs
Meaning of cancer to the patient

- metabolic disturbances such as liver failure

- loss of physical strength and well being

- fear of being abandoned as the disease progresses

- loss of independence

- lack of confiding relationships

- loss of role

- other life events or difficulties not related to cancer

- loss of personal relationships

- loss of life expectancy

Prevention of emotional problems

- loss of control - the younger patient, the greater the

impact

- offer information about illness and its treatment - may be

repeated later
- allow the patient to express emotional distress

Development of emotional problems

- provide ongoing care

- no psychiatric disorder: 50%

- adjustment reaction: 30%

Detection of emotional problems

- formal psychiatric diagnosis: 20%

- simple screening questionnaire repeated at regular

intervals

Factors contributing to psychological problems

- concern about prognosis and welfare of relatives

- ask patient from time to time how they have been coping
with the emotional side of illness and let them discuss their
current concerns

- poorly controlled physical symptoms eg pain, nausea,

breathlessness

Anxiety
- may be mixed with depression
- around time of initial diagnosis and while waiting for
results for suspected relapse

- interfere with treatment and diagnostic test

Denial
- unconscious refusal to acknowledge certain distressing
aspects of reality
- to protect themselves from anxiety and unpleasantness in
daily life

Risk factors for anxiety

- usually lasts not more than a few days

- harbouring underground fears about illness or its

treatment and too frightened to share with the staff

Suspect denial when

- seeks out more information than they can handle

- reactions

- inaccurate information from non-medical professionals

- looks for another physician in the hope of getting a

"better explanation"

- personality

- asks for repeated investigations, partially knowing that

the original diagnosis is correct
Effect of anxiety on cancer treatment
- chronically anxious patients would consult doctors
frequently and become hypochondriacal once the diagnosis
is confirmed

- fail to realize their diagnosis/prognosis

- fails to ask questions about the illness
- forgets the information given

- false alarms about spread of disease

- making unrealistic plans for the future

- very concerned about treatment and its side effects

- understands the matters in intellectual sense without

appropriate emotional distress

- avoidance of treatment
- may keep their symptoms a secret, resulting in a delayed
diagnosis

Adaptive denial
10

- denial acts as a buffer after unexpected news, allowing

patient to collect himself and mobilize other resources
- denial is a temporary defense and will be replaced by
partial acceptance
- it enables patients to acknowledge their cancer and
accept necessary treatment at one level of conscious
awareness

staff feels better but causes great distress to the

patient

- Middle approach

ample opportunity for patient to ask questions but

never forcing unwanted information upon them

- at another level they play down the seriousness of the

illness
- they may talk briefly about the reality of their situation
before indicating their inability to look at it realistically any
longer (daydream, fantasies, talking about brighter things
which contradict what he said earlier)
Maladaptive denial
- delays cancer diagnosis
- poor compliance

Anger
- transient anger is a normal phase in the adjustment
process

- blocked communication with relatives

- some patients may obtain relief through the spontaneous

free expression of anger before they move on towards
acceptance

Management of denial

- family and nurses find it hard to cope because anger is

displaced at all directions and projected at random

- Collusion

going along with the patient's view

kind to the patients but the staff feels uncomfortable

- Confrontation

- anger can be more marked in the relatives

- staff or family member should not react personally
because it feeds into the patient's hostile behaviour

challenging the patient with the truth

11

Types of anger
- free floating: angry about the unfairness of the illness,
blaming fate or God
- displaced: towards healthcare staff

- encourage redirection of anger and re-chanelling the

energy elsewhere eg exercise, music, creative activity and
cancer-related charity work
- medication: psychotropics

- justified: delay in making diagnosis

- suppressed: not co-operative and leads to depression

Depression in cancer
- usually associated with a great sense of loss
- financial burden

Why anger?
- comparing self with others - limited activity

- loss of job due to frequent absences or inability to

function

- asking for attention to make sure that he is not forgotten

- drugs: cytotoxics, steroids

- loss of control

Management of anger
- listen to patient, dont be defensive and dont make
judgments
- offer consistent professional care although the patient is
ungrateful
- facilitate a full blown expression of anger by a neutral
counsellor

Clinical presentation

- responding to criticisms of other doctors and nurses

- physical symptoms seem to be out of proportion to the

stage of cancer progression eg weight loss, anorexia,
fatigue

- colluding with the blame on colleagues is unwise and

unfair

- insomnia especially morning awakening

- anxiety
12

- difficult to control pain

- suicidal thoughts

Types of depression
- reactive depression

encouragements and reassurances

- preparatory grief

takes into account impending losses

allow patient to express their sorrow

- if depression persists after simple discussion, more

specialised treatment such as psychotherapy and
antidepressants will be required

Acceptance
- a stage where the patient is neither depressed nor angry
about his 'fate'
- almost void of feelings
- as if the struggle is over
- patient prefers to be left alone
- not in a talkative mood

Effect on cancer treatment

- communications become more non-verbal than verbal

- patient may consider themselves too worthless to get

help
- they do not complain
- poor quality of life

Management of depression
- let patient express their feelings of sadness and anger
- foster a 'fighting' spirit, but if patient is very depressed, it
can accentuate the sense of shame and failure

13

Personality Disorders
Social learning in childhood for antisocial behavior
CLUSTER A: Odd

- through growing up in an antisocial family

- through lack of consistent rules in the family

Paranoid

- learnt as a way of overcoming another problem

- Suspicious, sensitive, mistrustful, resentful, self-important

- from poor ability to sustain attention and other

impediments to learning

Schizoid
- Cold, detached, lack enjoyment, introspective

Schizotypal
- socially anxious, cognitive and perceptual distortions,
oddities of speech, inappropriate affective response,
eccentric behaviour

Borderline
- Identity disturbance, intense unstable relationships,
efforts to avoid abandonment, recurrent suicidal behavior,
transient stress-related paranoid ideation, impulsive,
difficulty controlling anger, unstable affect, history of
conduct disorder before 15

Histrionic

Antisocial

- Self-dramatization, suggestible, shallow and labile affect,

seeks attention and excitement, inappropriately seductive,
over-concerned with physical attractiveness, excessively
impressionistic speech, considers relationships more
intimate than they are

- Lack of concern for other's feelings, transient

relationships, irresponsible, impulsive and irritable, lack
guilt and remorse, fail to learn from adverse experience

Narcissistic

CLUSTER B: Dramatic

14

- Grandiose self-important, exploits others, requires

excessive admiration, envious and expects to be envied,
lacks empathy

CLUSTER C: Anxious
OTHERS
Avoidant
- feels socially inferior, preoccupied with possibility of
rejection, avoids involvement with new experiences and
people, avoid risk, avoid social activity, restraint in intimate
relationship from fear of being shamed or ridiculed,
inhibited in new personal situations due to feelings of
inadequacy

Dependent
- Allows others to take responsibility, unduly compliant with
wishes of others, feels unable to care for themselves, fear
of being left to care for themselves, difficulty initiating
projects, goes to excessive lengths to obtain support,
urgently seeks a supportive relationship

Passive-aggressive
- Passive resistance when given demands for adequate
performance

Depressive
- Persistently gloomy, strong sense of duty, little capacity
for enjoyment, unsatisfied with their life

Hyperthymic
- Habitually cheerful and optimistic, poor judgement, jumps
to conclusion, periods of irritability

Obsessive-compulsive

Cycloid

- Preoccupied with details/rules, inhibited by perfectionism,

over-conscientious, excessively concerned with
productivity, rigid and controlling, miserly, cannot discard
worthless or worn-out objects

- Extremes of depressive and hyperthymic personality

disorders

15

Stress Disorders
Acute stress reaction
- Freeze, fight, flight
- Avoidance and denial should recede as anxiety diminishes
to allow coming to terms with the stressful experience

- symptoms

re-experiencing of the event

avoidance of stimuli that arouse recollections of the
trauma
marked symptoms of anxiety or hyperarousal
significant distress or impaired social functioning
>3 of: sense of numbing/detachment, reduced
awareness of surroundings, derealization,
depersonalization, dissociative amnesia

Acute stress disorder

- onset while or after experiencing the distressing event

Management

- Lasts >2 days but <4 weeks

- assess by acute stress disorder interview, acute stress

disorder scale

- coping strategy: avoidance of reminders, use of alcohol or

drugs
- defence mechanisms: denial, displacement, regression

- Critical incident stress debriefing: facts, thoughts,

feelings, assessment, education
-reassurance that the condition is frequent and short-lived

Diagnosis

-short-term anxiolytic (if anxiety is severe) and hypnotic (if

severely disrupted sleep)

- stressor

-Follow-up within 1 month

exposure to event involving actual/threatened

death/serious injury to self or others
experience of fear/helplessness/horror or
disorganized/agitated behaviour in children

- prevention: cognitive behavioural intervention 2-weeks

post-trauma, prepare individuals 'at risk' (eg EMS and
military) by training to remain calm and objective, avoid
identifying with victims, express emotional reactions

16

PTSD
- traumatic event: experienced, witnessed or confronted
with an event that involved actual or threatened death or
serious injury or a threat to the physical integrity of self or
others
- etiology: fear conditioning, hypothalamic-pituitary-adrenal
axis abnormalities, or adrenergic effect on amygdala
- pre-disposing factors: women, family history of psychiatric
disorder, personal history of mood and anxiety disorder,
previous history of trauma, lower intelligence, lack of social
support

- significant distress or impaired social functioning for >1

month
- re-experience by >1 of

flashbacks
dreams
trauma re-enactment
distress or reactivity to cues resembling an aspect of
the event

'numbness'
restricted affect
sense of foreshortened future

- hyperarousal by >2 of

insomnia
irritability
poor concentration
hypervigilance
exaggerated startle response

- assess by clinician-administered PTSD scale (gold

standard) or post-traumatic stress diagnostic scale

- management: counselling, CBT, if patient prefers or if

psychotherapy unavailable then give SSRI or TCA and
continue for a year if good response

- avoidance of reminders by >3 of

thoughts
activities
inability to recall
reduced interest
17

Childhood disorders
Attention-deficit/hyperactivity disorder

- pattern of diminished sustained attention and higher

levels of impulsivity in a child or adolescent than expected
for someone of that age and developmental level
- more prevalent in boys

- attention-deficit disorder: persistent for at least 6 months

of > 6 symptoms of

failing to give close attention to details or makes

careless mistakes in activities,
often has difficulty sustaining attention in tasks or
play activities,
often does not seem to listen when spoken to
directly,
often does not follow through on instructions and
fails to finish chores,
often has difficulty organizing tasks,
often avoids/dislikes/reluctant to engage in tasks
that require sustained mental effort,
often loses things necessary for tasks,
often easily distracted by extraneous stimuli, often
forgetful in daily activities

- hyperactivity disorder: persistent of at least 6 months of

> 6 symptoms of

often fidgets with hands/feet or squirms in seat,

often leaves seat in situations in which remaining
seated is expected,
often runs about or climbs excessively in situations
in which it is inappropriate,
often has difficulty playing or engaging in leisure
activities quietly,
often "on the go" or acts as if "driven by a motor",
often talks excessively

- some symptoms that caused impairment were present

before 7 years old
- cognitive testing including a continuous performance task
(the child is asked to press a button each time a particular
sequence of letters or numbers flashes on the screen)

- first-line management: CNS stimulants methylphenidate

and dextroamphetamine
- second-line management

norepinephrine uptake inhibitor Atomoxetine,

antidepressant venlafaxine,
alpha-adrenergic receptor agonist clonidine
18

adherence to specific routines or rituals,

stereotyped and repetitive motor mannerisms

Autism
- more frequent in boys
- qualitative impairment in social interaction, impairment in
communication, restricted repetitive and stereotyped
patterns of behaviour/interests
- due to neuroanatomical or biochemical factors
- onset < 3 years of age of delays or abnormal functioning
in > 1 area (social interaction, language used in social
communication, symbolic or imaginative play)

- total of > 6 items with

- associated with congenital rubella, phenylketonuria,

tuberous sclerosis
- may be due to immunological incompatibility with mother
(maternal antibodies directed at fetus) or perinatal
complications

- management: target behaviours that will improve their

abilities to integrate into schools, develop meaningful peer
relationships and increase the likelihood of maintaining
independent living as adults

>2 from qualitative impairment in social interaction

lack of eye contact, facial expression and gestures,

no friends,
lack of social and emotional reciprocity

> 1 from qualitative impairments in communication

delay or lack of development of spoken language,

difficult to initiate and sustain a conversation,
stereotype and repetitive use of language or
idiosyncratic language

>1 of restricted, repetitive and stereotyped patterns of

behaviour/interest/activities

Rett's syndrome

- progressive condition of developmental deterioration with

onset after several months of apparently normal
development
- apparently normal prenatal and perinatal development
- apparently normal psychomotor development through the
first 5 months after birth
- normal head circumference at birth
19

- impairment and oddity of social interaction and restricted

interest and behaviour
- no significant delays occur in language, cognitive
development or age-appropriate self-help skills
- onset of all of the following after the period of normal
development:

deceleration of head growth between ages 5 and 48

months,
loss of previously acquired purposeful hand skills
between ages 5 and 30 months with the subsequent
development of stereotyped hand movements,
loss of social engagement early in the course,
appearance of poorly coordinated gait or trunk
movements,
severely impaired expressive and receptive language
development with severe psychomotor retardation

- symptomatic management: physiotherapy for muscular

dysfunction, anticonvulsants for seizures, behaviour
therapy and medication for control of self-injurious
behaviours

>2 of qualitative social impairment

>1 of restricted interest and patterns of behaviour

Asperger's syndrome

markedly abnormal non-verbal communicative

verbal gestures,
failure to develop peer relationships,
lack of social or emotional reciprocity,
impaired ability to express pleasure in other person's
happiness

preoccupation with one or more stereotyped and

restricted patterns of interest abnormal in
intensity/focus,
apparently inflexible adherence to specific nonfunctional routines or rituals,
stereotyped and repetitive motor mannerisms,
persistent preoccupation with parts of objects

20

- no clinically significant delay in cognitive development or

in the development of age-appropriate self-help skills,
adaptive behaviour and curiosity about the environment in
childhood
- no language delay, cognitive delay or adaptive
impairment

- factors associated with a good prognosis are a normal IQ

and high-level social skills
- supportive treatment: promotion of social behaviours and
peer relationships, self-sufficiency and problem-solving
techniques

Oppositional defiant disorder

- pattern of negativistic, hostile and defiant behaviours

lasting >6 months with presence of >4 symptoms of

often losing temper,

often arguing with adults,
often actively defies or refuses to comply with
adult's requests or rules,
often deliberately annoys people,
often blames others for their mistakes/misbehaviour,
often touchy or easily annoyed by others,
often angry and resentful,
often spiteful or vindictive

- positive outcomes are more likely for intact families who

can modify their own expression of demands and give less
attention to the child's argumentative behaviours
- management:

- a child's temper outbursts, active refusal to comply with

rules and annoying behaviours exceed expectations for
these behaviours for children of the same age

- in the absence of serious violations of social norms or of

the rights of others
- classic psychoanalytic theory implicates unresolved
conflicts as fuelling aggressive behaviours targeting
authority figures

family intervention using both direct training of the

parents in child management skills and careful
assessment of family interactions,
individual psychotherapy where the child is exposed
to a situation with an adult to practice more adaptive
responses,
self-esteem must be restored before a child with
oppositional defiant disorder can make more positive
responses to external control

Conduct disorder
21


- set of behaviours that evolves over time, usually
characterized by aggression and violation of the rights of
others
- associated with many other psychiatric disorders
including ADHD, depression and learning disorders
- also associated with certain psychosocial factors such as
harsh punitive parenting, family discord, lack of appropriate
parental supervision, lack of social competence, low
socioeconomic level
- average age of onset is 10-12 in boys and 14-16 in girls
- repetitive and persistent pattern of behaviour in which the
basic rights of others or major age-appropriate societal
norms or rules are violated

deliberately engaged in fire setting with the intention

of causing serious damage,
deliberately destroyed others' property,

deceitfulness or theft

broken into someone else's house/building/car,

lies to obtain goods or favours or to avoid
obligations,
stolen items of nontrivial value without confronting a
victim,

serious violations of rules

stays out at night despite parental prohibitions

before age of 13,
run away from home overnight at least twice while
living in parental or parental surrogate home or once
without returning for a lengthy period,
truant from school before 13 years old

- presence of >3 criteria in past 12 months with >6 months

of at least one criteria of
aggression to people and animals

bullies/threatens/intimidates others,
initiates physical fights,
used a weapon that can cause serious physical harm
to others,
physically cruel to people/animals,
stolen while confronting a victim,
forced someone into sexual activity,

- mild: few if any conduct problems in excess of those

required to make the diagnosis and conduct problems
cause only minor harm to others
- moderate: number of conduct problems and effect on
others intermediate between mild and severe
- severe: many conduct problems in excess of those
required to make the diagnosis or conduct problems cause
considerable harm to others

destruction of property
22

- good prognosis is predicted for mild conduct disorder in

the absence of coexisting psychopathology and the
presence of normal intellectual functioning
- those with severe conduct disorder are most vulnerable to
comorbid disorders later in life such as mood disorders and
substance use disorders

- management:

multimodal treatments using behavioural

interventions where rewards are earned for prosocial
and nonaggressive behaviours,
social skills training,
family education and therapy

23

Eating disorders
Anorexia nervosa
- self-induced starvation due to a relentless drive for
thinness/morbid fear of fatness resulting in medical signs
and symptoms of starvation
- behaviours and psychopathology are present for at least 3
months

- amenorrhoea (absence of >3 consecutive menstrual

cycles) in post-menarcheal females

Types
- restricting type: during current episode there was no
regular binge-eating or purging behaviour
- purging/binge-eating type: during current episode there
was regular binge-eating or purging behaviour.

- usually occurs between 10-30 years old

- associated with disturbances of body image, the
perception that one is distressingly large despite obvious
thinness
- co-morbidities include depression, social phobia and OCD
- starvation results in suppressed thyroid function,
hypercortisolemia, amenorrhea

Complications
- from weight loss

- refusal to maintain body at or above a minimally normal

weight for age and height (body weight <85% of expected)
- intense fear of gaining weight or becoming fat even
though underweight
- disturbance in the way in which one's body weight or
shape is experienced, undue influence of body weight or
shape on self-evaluation, or denial of the seriousness of the
current low body weight

loss of fat/muscle mass, reduced thyroid metabolism

(low T3), difficulty maintaining core body
temperature
loss of cardiac muscle, small heart, cardiac
arrhythmias, bradycardia, sudden death
delayed gastric emptying, bloating, constipation,
abdominal pain
amenorrhea, low LH and FSH
lanugo, edema
leucopenia
abnormal taste sensation, apathetic depression, mild
cognitive disorder
osteoporosis

- from purging
24

electrolyte abnormalities, seizures, mild

neuropathies, fatigue and weakness, mild cognitive
disorder
salivary gland and pancreatic inflammation and
enlargement with increase in serum amylase,
esophageal and gastric erosion, dysfunctional bowel
with haustral dilation
erosion of dental enamel (especially of front teeth)
with corresponding decay

- the disorder may run a chronic course but recovery can

occur even after many years
- indicators of favourable outcome: admission of hunger,
lessening of denial and immaturity, improved self-esteem
- usual causes of death are suicide or as a direct result of
medical complications

Management
- behavioural, interpersonal and cognitive approach,
comprehensive treatment plan involving both individual
and family therapy
- a reasonable aim is an increase of 0.5kg a week with the
target weight a compromise between a healthy weight (BMI
>20) and the patient's idea of what her weight should be
- monitor the patient's physical state regularly and
prescribe vitamin supplements if indicated

- eating as an inpatient should be supervised by a nurse

who has to reassure the patient that she can eat without
the risk of losing control over her weight, to be clear about
agreed targets and to ensure that the patient does not
induce vomiting or take purgatives

- admission to hospital is indicated if

the patient's weight is dangerously low

there is severe depression and suicidal risk
outpatient care has failed

Bulimia nervosa
- eating, in a discrete period of time, an amount of food
that is definitely larger than most people would eat
- a sense of lack of control over eating during the episode
- recurrent inappropriate compensatory behaviour in order
to prevent weight gain

Types
- purging: regularly engages in self-induced vomiting or the
misuse of laxatives, diuretics or enemas
- non-purging: uses other inappropriate compensatory
behaviours such as excessive exercise, but has not
25

regularly engaged in self-induced vomiting or the misuse of

laxatives, diuretics or enemas

- usually of normal weight

- most are female and often have normal menses
- onset in late adolescence, often following a period of
concern about shape and weight
- some may have a history of a previous episode of
anorexia nervosa
- there is an initial period of dietary restriction which, after
a variable length of time, breaks down with increasingly
frequent episodes of overeating
- as the overeating becomes more frequent, the body
weight returns to a more normal level
- episodes of bulimia may be precipitated by stress or the
breaking of self-imposed dietary rules, or may occasionally
be planned

Management
- most effective current treatment for bulimia nervosa is a
specific cognitive behaviour therapy that focuses on
modifying the behaviours and ways of thinking that
maintain the eating disorder
- antidepressant drugs such as SSRIs decrease the
frequency of binge eating and purging and improve mood
- the patient is more likely to wish to recover and a good
working relationship can often be established
there is no need for weight restoration
- it is necessary to assess the patient's physical state and
to measure electrolyte status in those who are vomiting
frequently or misusing laxatives

- voracious eating at first brings relief from tension but

relief is soon followed by guilt and disgust
Binge eating disorder
Complications
- repeated vomiting leads to potassium depletion, resulting
in weakness, cardiac arrhythmia and renal damage
- teeth become pitted by acidic gastric contents

- recurrent bulimic episodes in the absence of other

diagnostic features of bulimia nervosa, particularly counterregulatory measures
- patients may have depressive symptoms and some
dissatisfaction with their weight and shape, however the
latter are usually less severe
26

- appears to be associated with exposure to risk factors for

psychiatric disorder in general and for obesity
- generally affects an older age group than bulimia nervosa
and up to a quarter of those presenting for treatment are
men
- high spontaneous remission rate and seems reasonably
responsive to cognitive behaviour therapy and treatment
with SSRIs

27

Substance abuse
Abuse and dependence

Substance dependence: maladaptive pattern of substance

use leading to clinically significant impairment and
developing within 12 months >3 of:

Substance abuse: maladaptive pattern of substance use

leading to clinically significant impairment and developing
within 12 months >1 of:

recurrent substance use resulting in a failure to fulfil

major role obligations at work/ school/ home
recurrent substance use in situations in which it is
physically hazardous
recurrent substance-related legal problems
continued substance use despite having persistent
or recurrent social or interpersonal problems caused
or exacerbated by the effects of the substance

tolerance: defined as need for markedly increased

amounts to achieve desired effect/ markedly
diminished effect with continued use of same
amount
withdrawal manifested as characteristic withrdwal of
the substance/ the same substance is taken to
relieve or avoid withdrawal symptoms
the substance is taken in larger amounts or over a
longer period than intended
persistent desire or unsuccessful efforts to cut down
substance use
great deal of time spent in activities necessary to
obtain the substance or recover from its effects
important social, occupational or recreational
activities given up or reduced because of substance
use
substance use continued despite knowledge of
persistent physical or psychological problem likely
caused or exacerbated by the substance

Withdrawal symptoms
- Physiological reaction to lack of the substance depended
upon

28

- clinically significant maladaptive psychological or

behavioral changes
- >1 of
Alcohol
Excessive consumption of alcohol: weekly intake of alcohol
exceeding 21 units for men and 14 units for women

Alcohol misuse: drinking that causes mental, physical or

social harm to an individual

slurred speech,
incoordination,
nystagmus,
impairment in attention or memory,
stupor

Aetiology: genetic factors, abnormalities in alcohol

dehydrogenase leading to less sensitivity to acute
intoxication effects, learning factors, personality factors
(risk taking, novelty seeking, chronic anxiety)

CAGE questionnaire

Have you ever felt you ought to Cut down on

drinking?
Have people Annoyed you by criticizing your
drinking?
Have you ever felt Guilty about your drinking?
Have you ever had a drink first thing in the morning
as an Eye-opener to steady your nerves or get rid of
a hangover?
>2 positive replies implies alcohol misuse

Alcohol intoxication:
- recent ingestion of alcohol

Alcohol withdrawal:
- cessation of/ reduction in heavy/ prolonged alcohol use
- significant impairment in social/ occupational functioning
- >2 of

automomic hyperactivity,
hand tremors,
insomnia,
nausea,
transient visual/ auditory/ tactile hallucination,
psychomotor agitation,
anxiety,
grand mal seizures

29

- 6-8 hours after drinking: tremors in hands/legs, agitation,

nausea, insomnia
- 8-12 hours after drinking: misperceptions and
hallucinations
- 12-24 hours after drinking: seizure
- during 72 hours: delirium tremens
Alcohol dependence: >3 for 12 months
- tolerance,
- withdrawal,
- taking larger amounts over longer period of time than
intended,
- persistent desire or repeated unsuccessful efforts to cut
down or control,
- great deal of time spent in activities necessary to obtain
the substance/use/ recover from its effects,
- important social/ occupational/recreational activities given
up or reduced,
- continued use despite knowledge of persistent/recurrent
physical/psychological problem likely to have been
caused/exacerbated by the substance

Problem drinking: drinking has caused an alcohol-related

disorder or disability

Social dysfunction

family: domestic violence/neglect

accidents: DUI
work problems: absconding, poor performance
crime: assault, rape
decision making: unprotected sex, illicit drugs, body
modifications

Biological dysfunction

direct toxic effect on brain and liver

poor diet causing vitamin B and protein deficiency
accidents and falls
general neglect of hygiene
fetal alcohol syndrome
peripheral neuropathy, dementia, cerebellar
degeneration
gastritis, liver damage, acute/chronic pancreatitis
severe muscle wasting, osteoporosis, osteomalacia
increased BP, increased stroke risk
anemia, myopathy

Psychological dysfunction

idosyncratic intoxication: marked change in

behaviour in amounts of alcohol that would not
induce drunkenness in most people
memory blackouts: single episode - not habitual
alcohol abuse, regular episodes - frequent heavy
drinking, prolonged episodes - sustained excessive
drinking
30

delirium tremens: MEDICAL EMERGENCY

Wernicke's encephalopathy: due to thiamine
deficiency, delirium + ophthalmoplegia+ nystagmus
+ ataxia, treat with pabrinex or benzodiazepine
Korsakoff's syndrome: retrograde and anterograde
amnesia due to thiamine deficiency, confabulation
Alcoholic dementia: intellectual impairment due to
prolonged, heavy intake of alcohol
transient hallucinations: during withdrawal
alcoholic hallucinosis: distressing auditory
hallucinations which may be followed by persecutory
delusions, happens when normal blood alcohol levels
drop, responds to antipsychotics
cerebellar degeneration - severe limb ataxia +
dysarthria + slurred speech + nystagmus due to
toxic effect on Purkinje cells of cerebellar cortex
Marchiafava-Bignami syndrome: demyelination and
necrosis of middle 2/3 of corpus callosum
depressive disorder
pathological jealousy
sexual dysfunction

Delirium tremens

24-48 hours after stopping heavy, prolonged

drinking,
delirium,
coarse tremors
sympathetic overdrive increase heart rate and BP,
electrolyte disturbance,
liliputan hallucination,

insomnia
dehydration
Manage with rehydration, thiamine, folic acid,
diazepam, correction of electrolyte imbalance,
antipsychotic or anticonvulsants if necessary

Management of alcohol dependence:

motivational interviewing
total abstinence vs controlled drinking
prevent major complications of withdrawal
group therapy, couple therapy, cognitive-behavioural
therapy

Abstinence maintenance:

disulfiram: blocks oxidation of alcohol causing

acetaldehyde accumulation, anticipation of
unpleasant reaction deters from impulsive drinking
acamprosate: stimulate inhibitory effect of GABA and
decrease excitatory effect of glutamate, to remain
alcohol-free after detoxification
naltrexone: reduce craving, short-term treatment

Prevention:

raise awareness

31

change level of drinking: economic control, formal

control (licensing laws), informal control (customs
and moral beliefs)

- detectable for 4 days

Amphetamine side effects

- (life-threatening) myocardial infarction, severe
hypertension, cerebrovascular disease, ischemic colitis,
tetany, seizures, coma
- (non-life-threatening) flushing, pallor, cyanosis, fever,
headache, tachycardia, nausea, bruxism, shortness of
breath, ataxia

Recreational drugs

- (in pregnancy) low birth weight, small head

circumference, early gestational age, growth retardation

Amphetamine

- (psychological) restlessness, dysphoria, irritability,

insomnia, hostility, confusion, paranoid delusions,
hallucinations, anxiety

Amphetamine and similar substances:

Amphetamine intoxication:

- MDMA (ecstasy), LSD, ketamine, Rohypnol

- recent use of methamphetamine or a related substance

Amphetamine use:
- taken orally, snorted, injected
- Symptoms: Elation, euphoria, friendliness, decreased
fatigue, induction of anorexia, heightened pain threshold,
increased self-confidence, increased sensory sensitivity
- lasts 4 to 8 hours

- clinically significant maladaptive behavioral or

psychological changes
- >2 of

tachycardia or bradycardia
pupillary dilation
increased or lowered blood pressure
perspiration or chills
nausea or vomiting
32

evident weight loss

psychomotor retardation or agitation
muscular weakness/ respiratory depression/ chest
pain/ cardiac arrhythmias
confusion/ seizures/ dyskinesias/ dystonias/ coma

- Symptoms: paranoia, predominant visual hallucinations,

appropriate affect, hyperactivity, hypersexuality, confusion
and incoherence
- treatment: short-term haloperidol

Amphetamine withdrawal:
- cessation of/ reduction in amphetamine use that has been
heavy or prolonged
- dysphoric mood and >2 of

Amphetamine-induced psychotic disorder:

fatigue
vivid unpleasant dreams
insomnia or hypersomnia
increased appetite
psychomotor retardation or agitation

Cannabis

Cannabis and similar substances:

- marijuana, grass, weed, pot, tea, Mary Jane, hemp,
chasra, bhang, ganja, dagga, sinsemilla
- smoked

Cannabis intoxication:
- recent use of cannabis

Management:
- diazepam for agitation and hyperactivity,
- bupoprion for withdrawal

- clinically significant maladaptive behavioural or

psychological changes
- within 2 hours develops >2 of

conjunctival injection
33

increased appetite
dry mouth
tachycardia

Cannabis side effects

- (short-term) dilation of conjunctival blood vessels, mild
tachycardia, orthostatic hypotension
- (cognition, short-term) impaired memory, reaction time,
perception, motor coordination, attention, consciousness
- (long-term) cerebral atrophy, lowered threshold for
seizure, chromosomal damage, birth defect, impaired
immune reactivity, alteration in testosterone concentration,
dysregulation of menstrual cycle

Cocaine

- lasts for 30-60 minutes

- detectable for 10 days

Cocaine side-effects:
- (non-life threatening) nasal congestion, serious
inflammation, swelling + bleeding + nasal ulceration of
nasal mucosa, development of acute dystonia, tics,
migraine-like headaches
- (long-term) perforation of nasal septa, damaged bronchial
passages,
- (life-threatening) non-haemorrhagic cerebral infarctions,
seizures, myocardial infarctions, arrhythmias, respiratory
depression

Cocaine intoxication:
- recent use of cocaine

Cocaine and similar substances:

- rocks (crack)
- injected, smoked, snorted, inhaled

Cocaine use:
- alert, euphoria, sense of well-being, heightened selfesteem, decreased hunger, less need for sleep, improved
mental and physical tasks

- clinically significant maladaptive behavioural or

psychological changes
- >2 of

tachycardia or bradycardia
pupillary dilation
elevated or lowered blood pressure
perspiration or chills
nausea or vomiting
evident weight loss
34

psychomotor agitation or retardation

muscular weakness/ respiratory depression/ chest
pain/ cardiac arrhythmias
confusion/ seizures/ dyskinesias/ dystonias/ coma

- paranoid delusions, auditory hallucinations, formication,

grossly inappropriate sexual and generally bizarre
behaviour

Cocaine withdrawal:
- cessation of cocaine use that has been heavy and
prolonged

Hallucinogens

- lasts for 18h in mild to moderate use, 1 week in heavy

use

Hallucinogens and similar substances:

- dysphoric mood and within a few hours >2 of

- LSD, mescaline, MDMA (ecstasy), morning glory, DMT

fatigue
vivid unpleasant dreams
insomnia or hypersomnia
increased appetite
psychomotor retardation or agitation

Cocaine-induced psychotic disorder symptoms:

Hallucinogen use:
- tablets, blotter acid
- symptoms: increased deep tendon motor reflexes,
increased muscle tension, ataxia, increased respiration,
increased blood pressure, decreased appetite, salivation,
synesthesia, visual hallucinations, intense transient
emotions, increased suggestibility
35

- lasts 8 to 12 hours

tremors

- treatment: diazaepam (20mg oral)

incoordination
- treatment: antipsychotics, lithium, carbamazepine

Hallucinogen side effects:

- (biological) tremors, tachycardia, hypertension,
hyperthermia, blurring of vision, mydriasis
- (psychological) chronic anxiety, depression

Hallucinogen Persisting Perception Disorder:

- symptoms: re-experiencing of perceptual symptoms
experienced while intoxicated following cessation of use,
spontaneous, transitory
- comorbidities: panic disorder, major depression, alcohol
dependence

Hallucinogen intoxication:
- recent use of a hallucinogen

Opioid

- clinically significant maladaptive behavioural or

psychological changes
- perceptual changes occurring in a state of full
wakefulness and alertness

Opioid and similar substances:

- morphine, heroin, methadone, codeine, vicodin

- >2 of
pupillary dilation

Opioid use:

tachycardia

- orally, snorted, IV, subcutaneous injection

sweating

- symptoms: euphoria followed by sedation, warmth, heavy

extremities, dry mouth, itchy face, facial flushing

palpitations
blurring of vision

36

Opioid side effects:

fever
insomnia

- respiratory depression, pupillary constriction, smooth

muscle contraction, constipation, changes in blood
pressure/ heart rate/ body temperature

- onset within 8-12 hours after last dose, peak at 24-48

hours and subsides over 10 days

Opioid intoxication:

Treatment

- recent use of an opioid

- clinically significant maladaptive behavioural or
psychological changes
- pupillary constriction and >1 of

drowsiness or coma
slurred speech
impairment in attention or memory

Opioid withdrawal symptoms:

methadone (substitution therapy)

clonidine (for methadone withdrawal),
naloxone (esp in overdose),
naltrexone (for rapid detoxification in withdrawal
symptoms)

Barbiturate withdrawal in a habitual abuser is a wellrecognised cause of fits together with the altered
behaviour.

- cessation of or reduction in opioid use that has been

heavy and prolonged/ administration of an opioid
antagonist after a period of opioid use
- >3 of

dysphoric mood
nausea or vomiting
muscles aches
lacrimation or rhinorrhea
pupillary dilation or piloerection or sweating
diarrhea
yawning
37

Schizophrenia and mood disorders

Schizophrenia
- >2 of

delusions
hallucinations
disorganized speech
disorganized or catatonic behaviour
negative symptoms

- 1 month of symptoms + 5 months of residual symptoms

Types
- paranoid: persecutory delusions with auditory
hallucinations
- disorganized: disorganised behaviour with disorganized
speech and affective blunting
- catatonic: presence of 2 or more of

motor immobility,
catatonic excitement,
repetitive behaviour or speech

- simple: insidious development of odd behaviour, social

withdrawal and declining work performance
- undifferentiated: equally prominent features of >1 type

Negative symptoms

alogia
affective flattening
avolition
anhedonia
attention reduced

Schneider's Positive symptoms

Auditory hallucinations
Broadcasting of thoughts
Control delusions (control by an external force)
Delusional perception

- residual: chronic schizophrenia >1 year with persistent

negative symptoms but no recurrence of positive
symptoms

Depression in schizophrenia is due to

part of schizophrenia, remits with psychosis

recovery of insight into nature of illness and future
problems
side-effect of antipsychotics

38

Schizophreniform psychosis
Good prognostic indicators for schizophrenia

Female
Late onset
Good premorbid level of functioning
No family history
Acute onset
Prominent positive symptoms
Good social relationships
Duration of untreated psychosis is less than a year

>2 of

delusions
hallucinations
disorganized speech
disorganized or catatonic behaviour
negative symptoms

- lasts >1 month but <6 months

Brief psychotic disorder

Treatment- resistant schizophrenia

- >1 of

- patient continues to experience psychotic symptoms in

spite of trying a number of antipsychotics of the typical and
atypical group in sufficient dose for an adequate trial
period

delusions
hallucinations
disorganized speech
disorganized or catatonic behaviour
negative symptoms

- lasts > 1 day but recover in < 1 month

Schizoaffective disorder
- An uninterrupted period of illness during which there is
either a Major Depressive Episode, a Manic Episode, or a
Mixed Episode concurrent with symptoms that meet
Criterion A for Schizophrenia.

39

- During the same period of illness, there have been

delusions or hallucinations for at least 2 weeks without
prominent mood symptoms.

- extreme fatigue and heaviness in limbs

- pronounced anxiety

- Bipolar type (Mixed or Manic episode) or Depressive type

(only depressive episode)
Depression

Types

- depressed mood/ loss of interest with >4 of

- mild: worse in the evening, start at time of misfortune and

ends when fortune changes

change in appetite or significant weight loss

insomnia or hypersomnia
observed psychomotor agitation or retardation
fatigue or loss of energy
feelings of worthlessness or guilt
diminished ability to think or concentrate
recurrent thoughts of death or suicidal ideation

- moderate: worse in the morning, neglected grooming

- severe: inattention to basic hygiene and nutrition,
complete loss of social/ occupational function

Dysthymia

- present >2 weeks

- chronic depressive state

Depression with psychosis

Cyclothymia

- as above + presence of delusions or hallucinations on

worthlessness, guilt or ill-health

- persistent instability of mood with episodes of mild

elation/ mild depression

Atypical

Differential diagnosis:

- variably depressed mood with mood reactivity to positive

events
- overeating/ oversleeping

Bipolar
Adjustment disorder
Dysthymic disorder with long-standing symptoms
Depression due to general medical condition
40

Medication/illicit drug use

Menopause
Post-partum blues/depression

Management
- Psychotherapy

Counselling
Problem solving
CBT

- Pharmacotherapy

SSRI
TCA

- Insomnia

SSRI sedative eg Fluvoxamine, sertraline

TCA amitriptyline, imipramine
Sleep hygiene

- Add benzodiazepine

If patient is anxious with no history of adverse

effects with benzodiazepine, esp when using SSRI
First 2 weeks of SSRI use can cause paradoxical
anxiety

- Indications for ECT

Life-threatening condition eg refusal to eat or high

suicidality

Moderate or severe depression for short-term

therapeutic benefits
Psychotic depression
Treatment resistant
Poor response/intolerance to medication
High degree of symptom or functional impairment

- Duration of treatment

1st episode: 6 9 months after remission

2nd episode: continue antidepressants 2 3 years
after remission
3rd episode: lifelong

Counselling for treatment

Anti-depressants may take 2-4 weeks for visible

effects but must be taken continuously without
stopping
Start with low dose but may have to increase dose
for optimal response
Benzodiazepine is for short-term, will need to be
stopped once the anti-depressants begin to work
The anti-depressants must be taken for at least 6
months (in first episode of depression)
There may be a relapse after which the duration of
treatment will be longer
The medication needs to be tapered down gradually.
Avoid abruptly stopping medication (to avoid SSRI
discontinuation syndrome)

41

Treatment-resistant
-

Failed to response to >2 antidepressant treatments

at an adequate dose for an adequate duration of at
least 4 weeks
Treat by switching to another antidepressant (either
from the same class or different class), augment with
lithium/olanzapine, combine with another
antidepressant

Depression in elderly
-

Declining senses/cognitive deficit/sexual changes

Medical cause: Distress due to illness/side effect of
medication/ painful procedures/dependency
Social cause: Retirement, multiple bereavements,
empty nest syndrome, isolation/loneliness,
physical/emotional abuse, vagrancy

Suicide risk
S Sex
(male)/single/separated/divorced/widowed/schizophrenia
U Unemployment
I Illicit drug use
C Chronic medical condition with poor symptom control
I Inheritance (Family history of suicide)/intend to die
D Depression
A Attempted before/anxiety disorder/age >40
L Life event

Investigations

TFT, VDRL, ESR

Urine screening for drugs esp amphetamine-type
stimulants
CT brain if focal neurological deficit
present/suspected SOL
EEG suspected seizure disorder
Baseline investigations before starting therapy (FBC,
RBS, lipid profile, RP, LFT, ECG)

Indications for admission

Risk of harm to self

Psychotic symptoms
Inability to care for self
Lack of impulse control
Danger to others

SAD PERSONS SCALE risk assessment

Sex
Age
Depression
Prior history
Ethanol abuse
Rational thinking
Support system loss
Organized plan
42

No significant other
Sickness

- 0-2 no real problem

- 3-4 send home but check frequently
- 5-6 consider hospitalization if assured that patient will
return for review
- 7-10 definitely hospitalization

Bipolar mood disorder

Hypomania
- persistently elevated or irritable mood >4 days
- >3 of

grandiosity
decreased need for sleep
pressured speech
flight of ideas
distractible
goal-oriented activity
excessive involvement in pleasurable activities with
painful consequences

Mania
- persistent elevated or irritable mood >1 week

Mixed: both mania and major depressive episode >1 week

- >3 of

grandiosity
decreased need for sleep
pressured speech
flight of ideas
distractible
goal-oriented activity
excessive involvement in pleasurable activities with
painful consequences

Rapid cycler: >4 mood swings in 1 year

Treatment for mania

sodium valproate,
olanzapine,
chlorpromazine,
haloperidol,
quetiapine,
aripirazole,
risperidone,
43

ECT

Treatment for depression

SSRI Fluvoxamine
Lamotrigine,
Lofepramine (AVOID if suicidal),
ECT

Maintenance

lithium,
carbamazepine (esp rapid-cycling)
lamotrigine

High risk clinical factors for suicide include:

Severe insomnia
Self neglect
Memory impairment
Agitation
Panic attacks
Pessimism
Despair
Anhedonia,
Morbid guilt.

Other factors predicting high risk are:

Declared intent
Preparation
Past history of Deliberate self-harm
Severe depression
Schizophrenia
Substance abuse,
The use of a potentially lethal method.

Factors predicting a greater risk of future episodes

Incomplete symptomatic remission

Early age of onset
Poor social support
Poor physical health
Comorbid substance misuse
Comorbid personality disorder

- interval between episodes becomes progressively shorter

with both age and the number of episodes

44

Suicide and Deliberate Self-harm

Suicide

Reasons for higher suicide rates in men

Men are less likely to seek help for emotional

problems.

Men are more impulsive than women.

Men are less socially embedded than women.

Men may choose more lethal methods

Risk factors for suicide

Patient demographics: increasing age and male

gender

Past and current suicidality (50% more likely)

Psychiatric diagnosis and psychiatric symptoms

Individual history: Medical history, family history,

psychosocial history

Personality strengths and weaknesses.

Reasons for higher suicidal behaviours in the elderly

Risk factors for suicidal behaviours in women

Intimate partner/spouse abuse

Gender inequalities in some society/within the family.

Severe psychiatric illness following delivery e.g.

postpartum depression and postpartum psychosis.

Less physical resilient: suffering from physical illness.

More likely to have access to medication: overdose

Poverty and isolation: less likely to be rescued

Presence of longstanding medical problems

Generally demonstrate a greater determination to

die as they give few warning signs

Psychiatric illness esp depression, alcohol abuse

Involve greater planning and use more lethal

methods.

Social isolation / poor support

Characteristics of past attempts that increases future risk

45

Past attempt with adverse consequences e.g.

disability

high intent

Use of highly lethal means

Measures taken to avoid discovery

Protective factors for suicide

Optimism
Religiosity
High life satisfaction

Risk of successful suicide in current suicidal ideation

the magnitude of suicidal thoughts is greater and

persistent.

The intent is higher (patients expectation to die)

Detailed and specific suicide plan

Aspects of suicide plan associated with higher lethality

Psychiatric symptoms associated with suicide

Mood disorder esp depression

hopelessness

Psychotic disorder with command hallucinations

Impulsivity

aggression

Panic disorders

Method: higher lethality method is associated with

higher suicide risk.

Patients belief about the lethality of the method

(high intent)

Personality disorders

Substance abuse and dependence

Low chance of rescue

Anger

Steps taken to enact plan: hoarding pills, plan the

time and setting, ensuring isolation and low chance
of discovery.

Side effects of Rx e.g., akathisia

higher risk is associated with individuals who are

also socially isolated, with maladaptive coping and
experiencing significant loss (e.g. financial)

Preparedness of death: making a will, writing letters

to loved ones, suicide notes.

46

To get help

Specific questions in assessment of the patient

Deliberate Self-Harm

What were their intentions when they harmed

themselves?
Do they now intend to die?
What are their current problems?
Is there a psychiatric disorder?
What helpful resources are available?

Management
Predisposing factors

Early parental loss or a history of parental neglect or

abuse
Borderline or paranoid personality disorders
Long-term problems in a relationship with a partner
Unemployment and financial difficulties
Poor physical health

Psychoeducation
Cognitive behavioural therapy

Reasons for deliberate self-harm

To
To
To
To
To
To
To

die
escape from unbearable anguish
get relief
change the behaviour of others
escape from a situation
show desperation to others
get back at others/make them feel guilty
47

Anxiety disorders

- Worry about the meaning or consequences of attacks

- Significant change in behavior related to the attacks

Fear is a response to a known, external, definite, or nonconflictual threat

- With or without agoraphobia

- can be due to

Anxiety is a response to a threat that is unknown, internal,

vague, or conflictual

Panic disorder

- Recurrent unexpected panic attack

- 4 or more of

palpitations,
sweating,
trembling,
SOB,
chest pain,
air hunger,
dizzy,
derealization,
nausea,
numbness,
chills

- Persistent concern of future attacks

dysfunction of noradrenergic neurons of the locus

ceruleus,
panic-inducing substances,
pathological involvement in the temporal lobes,
classic conditioning or from parental behaviour,
unsuccessful defences against anxiety-provoking
impulses

- management: CBT, relaxation therapy, exposure therapy,

antidepressants, benzodiazepine

Agoraphobia

- anxiety about being alone in situations or places which

are perceived as being difficult to get help if a subsequent
panic attack occurs

- Marked and consistently manifests fear in or avoidance of

>2 of

crowds,
48

public places,
traveling alone
traveling away from home

- >2 anxiety symptoms present together in the feared

situation on at least 1 occasion since the onset of the
disorder and 1 of the symptoms are

autonomic arousal symptoms (palpitations,

sweating, dry mouth),
symptoms involving chest and abdomen (difficulty
breathing, feeling of choking, chest pain, nausea),
symptoms of mental state (dizzy, derealization, fear
of losing control, feat of dying)
general symptoms (hot flushes or cold chills,
numbness)

- significant emotional distress caused by avoidance or by

the anxiety symptoms
- symptoms are restricted to or are predominant in the
feared situations or contemplation of the situation

- management: antidepressants, anxiolytics, CBT

of being the focus of attention/situations where there is

fear of behaving in a way that will be embarrassing

- >2 anxiety symptoms manifested at some time since the

onset of the disorder together with >1 of

blushing/shaking,
fear of vomiting,
urgency or fear of micturition or defecation

- Significant emotional distress is caused by the symptoms

or by the avoidance, and the individual recognizes that
these are excessive or unreasonable
- Symptoms are restricted to, or predominate in, the feared
situations or contemplation of the feared situations
- due to conditioning, excessively high standards for social
performance, negative beliefs about self, excessive
monitoring of their own performance in social situations

Management: CBT, dynamic psychotherapy, SSRI

Fluvoxamine or Sertraline, Phenelzine

Social phobia
Specific phobia
- Presence of either fear of being the focus of attention or
behaving in a way that will be embarrassing or avoidance

49

- Marked and persistent fear or avoidance of a specific

object that is excessive or unreasonable
- exposure to the phobic stimulus almost invariably
provokes an immediate anxiety response
- phobic situation is avoided
- Recognition that the fear is excessive or unreasonable
- Symptoms restricted to the feared situation or
contemplation of the feared situation
- due to persistence of childhood fears, conditioning,
stimulation in the anterior cingulate
cortex/amygdala/hippocampus

- management: exposure, benzodiazepines for short term

relief

- Obsessions cause marked distress, are time-consuming

(>1h/day) or cause significant impairment in social,
occupational or other daily functioning
- onset after 35 requires a complete neurologic evaluation
- management: relaxation therapy, CBT (mild) (thought
stopping, response prevention), SSRI (moderate)
(Fluvoxamine, Fluoxetine, Sertraline), SSRI and CBT (severe
functional impairment)

Generalized anxiety disorder

- Excessive anxiety and worry about a number of events or
activities (future oriented), occurring more days than not
for at least 6 month
- Worry is difficult to control
- Worry is associated with >3 of

Obsessive-Compulsive disorder

- Obsessions: recurrent and persistent thoughts, impulses,

or images that are experienced as intrusive and
inappropriate
- Compulsions: repetitive behaviors or mental acts whose
goal is to prevent or to reduce anxiety or distress

restlessness,
easily fatigued,
difficulty concentrating,
irritability,
muscle tension,
sleep disturbance

- Anxiety and worry cause significant impairment in

occupational, social or other daily functioning

- Recognition that the fear is excessive or unreasonable

50

- management: CBT, SSRI Sertraline or escitalopram,

Propanolol, TCA, Benzodiazepine

- Age of onset before 18 years old

- Causes distress or impairment in functioning
- Physical symptoms when separation occurs or is
anticipated

- management:

reduce stressors,
talk about their worries,
psychoeducation,
anxiolytic drugs for short-term if very severe anxiety

Separation anxiety disorder

- Developmentally inappropriate and excessive anxiety
concerning separation from home or to an attachment
figure
- >3 of

recurrent and excessive distress when separation

occurs or is expected,
persistent and excessive worry that attachment
figure will be lost or harmed,
persistent and excessive worry that an event will
lead to separation from attachment figure,
persistent and recurring fear of being alone without
attachment figure at home,
reluctance or refusal to sleep away from home or
without attachment figure

- Duration of at least 4 weeks

51

Pregnancy-related depression

- Disinterest in the newborn / fearful of being left alone with

the baby.

Depression during pregnancy

- Increased risk of suicide, neglect of the newborn and

infanticide

- Depressed mood, anxiety

- Treatment includes psychotherapy and antidepressants if
depression is severe

- Treatment includes antidepressants Fluoxetine (SSRI) or

Dothiepin (TCA), ECT and psychotherapy
- Risk of recurrence is 50%

- Increased likelihood of postpartum depression

Postpartum psychosis
Postpartum blues

- Onset usually within the first month

- Onset within 2 weeks postpartum

- usually in primiparous or when there is a history of

perinatal complications

- Presents with depressed mood, irritability, mood swings,

crying spells, fatigue, anxiety
- Treatment includes support, reassurance, education
- Symptoms tend to remit spontaneously by the 10th day

- Early stages similar to postpartum blues, progress to

frank psychosis with suspiciousness, delusions,
hallucinations which may involve the child
- may have impulses to harm the child
- agitated, poor sleep

Postpartum depression
- Onset within first 3 months
- Similar to major depressive disorder but tend to
experience more mood fluctuation and prominent anxiety
symptoms.

- Treatment includes ECT, antipsychotics with mood

stabilizers if bipolar in presentation and antipsychotics with
antidepressants if depressed
- Advice on non-hormonal contraception
- Risk of recurrence is 70%

52

Cognitive disorders
Precipitating factors
Delirium

- Acute global cognitive impairment in the setting of

clouded consciousness (patient is awake but has reduced
awareness of environment and is unresponsive)

drugs (narcotics, polypharmacy),

primary neurological disease,
intercurrent illness,
surgery,
environmental (physical restraint, ICU admission,
multiple procedures)

- often reversible and brief

Pathophysiology
Predisposing factors

age >65,
male,
cognitive impaired (dementia, depression),
function impairment (functional dependence,
immobility),
sensory impairment,
decreased oral intake,
substance use,
coexisting medical conditions

cholinergic deficiency,
dopamine (regulates acetylcholine),
changes in BBB

Diagnosis

disturbance of consciousness with reduced ability to

focus, sustain/shift attention,
change in cognition or development of perceptual
disturbance,
development of disturbance over a short period of
time (hours to days) and fluctuates

53


Types

Delirium due to a general medical condition

(evidence from history, PE or laboratory findings) eg
meningitis, head injury, stroke, UTI, chest infection,
PE, MI, arrhythmia, hepatic encephalopathy,
hyper/hypoglycemia in diabetes, epilepsy,
malignancy
delirium due to intoxication (symptoms developed
during substance intoxication, medication use is
etiologically related to the disturbance, cognitive
symptoms are in excess of intoxication syndrome) eg
insulin, digoxin, lithium, opiates, benzodiazepines
delirium due to substance withdrawal (symptoms
developed during or shortly after a withdrawal
syndrome, cognitive symptoms in excess of
withdrawal syndrome),
delirium due to multiple etiology,
delirium not otherwise specified

either disorganized thinking or altered level of

consciousness)
Abbreviated Mental Test Score to establish cognitive
deficits present on admission and for a baseline
score for assessing progress

Non-pharmacological management

avoid extremes of sensory input,

relief of distress,
control agitation and prevent exhaustion,
psychosocial support

Pharmacological management

ensure drug treatment for underlying physical

problem is the minimum required
antipsychotics for agitated patients with perceptual
disturbances,
treatment of specific etiologies

Investigations

Delirium Rating Scale evaluates temporal onset of

symptoms, fluctuation, perceptual disturbances and
hallucinations,
Confusion Assessment Method tool (requires acute
onset and fluctuating course with inattention and

Dementia

- global impairment of intellect without impaired

consciousness

54

- cognitive functions affected include memory, orientation,

perception and attention, judgment, language and problem
solving and abstract thinking
- score of <23 out of 30 in MMSE is suggestive of cognitive
impairment
- interferes with social and occupational functioning

Losing your train of thought?

Problems trying to find the right word?
Difficulty following conversations?
Forgetting to turn things off such as the lights or
stove?
Keeping track of time?
Others expressing concern about your memory?

- patients may have episodes of violence or abuse towards

others and self-harm in advanced dementia
- patients are vulnerable to physical, mental and financial
abuse by others
Reversible causes of dementia

Hypothyroidism
Vit B12 deficiency
Subdural haematoma
Uremia
Normal pressure hydrocephalus
Syphilis

Function
4 instrumental activities of daily living
- Ask caregiver whether pt needs assistance in these areas:

Money management
Medication management
Telephone use
Traveling

Irreversible causes of dementia

Alzheimer's disease
Vascular dementia
AIDS

Questions to elicit type of memory difficulties

Being more forgetful?

Lewy body dementia

- hallmarked by the presence of Lewy bodies within the

brain stem and neocortex
- features of parkinsonism which fail to respond to therapy
and fluctuating cognitive loss
55

- onset of cognitive impairment should be before or within

one year of extrapyramidal features

Alzheimer's dementia

- cognitive decline occurring more than one year after

onset of motor symptoms is suggestive of Parkinson's
disease with dementia

- characterised by progressively impaired cognition and

behavioural change
- caused by a progressive neuronal damage, accumulation
of -amyloid peptide, senile plaques and neurofibrillary
tangles, widened ventricles
- patients show deficits of visual-spatial skill, memory, and
cognitive capabilities e.g. problem solving, word finding
and speech, navigation, arithmetic, writing or reading.

Vascular dementia

- diagnosis is made by excluding treatable dementias

- criteria for Alzheimers dementia

- comprise 25% of all dementias

- large vessel disease: multi-infarct dementia, strategic
infarct dementia
- small vessel disease: lacunar state, Binswanger disease
(subcortical arteriosclerotic encephalopathy, may have
small infarcts of white matter with sparing of cortical
regions)
- effects occur in a stepwise progression (ie memory
plateaus then worsens after a further stroke)

Memory impairment
At least one of: aphasia, apraxia, agnosia,
disturbance in executive functions
Impairment in occupational or social functioning
Decline from previous level of functioning
Not occurring exclusively during the course of
delirium

- risk factors

- linked to a history of multiple strokes or TIAs

- remains at a fixed MMSE

Age >65
First degree relative with Alzheimers (increases risk
of early onset Alzheimers)
Head trauma with loss of consciousness and
vascular damage (Brain injury may trigger the
production of -amyloid.)
56

Menopause (Loss of estrogen which promotes neural

growth)
Less intelligence and less formal education
(Less synaptic connections.)
Individuals with less physical and mental activity

- Glutamate and NMDA receptor inhibitor (Memantine) or

Acetylcholinesterase inhibitors (eg rivastigmine, donepezil)
in mild to moderate Alzheimer's disease with MMSE
between 10-20 and in people with severe functional
impairment in comparison to premorbid status if MMSE >20

Difficulty recognizing familiar people

Severe symptoms

Loss of speech
Loss of appetite and weight loss
Loss of bladder and bowel control

- antipsychotic drugs for severe non-cognitive features

such as psychosis and severe challenging behaviour which
is a risk to the patient and others
- MMSE drops by 3 points every year without treatment
- MMSE drops 1-2 points every year with treatment
Mild symptoms

Confusion and memory loss

Disorientation
Problems with routine tasks

Frontotemporal dementia

- umbrella term for uncommon disorders primarily affecting

the frontal and temporal lobes of the brain
- typically occurs between ages 40 and 70

Moderate symptoms

Difficulties with activities in daily living such as

dressing, bathing and shopping
Anxiety, aggression, agitation and suspiciousness
Sleep disturbances
Wandering, pacing

- Pick's disease: gliosis, neuronal loss, neuronal Pick's

bodies, personality and behavioural changes with relative
preservation of cognition
- Huntington's disease: subcortical dementia, psychomotor
slowing, choreoathetotic movements, relatively intact
memory/language/insight
57

Pseudodementia

- In depression the cognitive deficit (if present) is typically

acute and recent (while Alzheimer's disease is typically
insidious)
- The depressed patient will often communicate a sense of
distress and agitation, and the depression will be
associated with typical features e.g. positive diurnal mood
variation and early morning waking.
- Other clinic features favouring a diagnosis of depression
include family history of previous episodes, and
precipitating life events.

- Thiamine deficiency may be secondary to alcoholism,

vomiting during pregnancy, dietary insufficiency or gastric
carcinoma.
- Treatment is with urgent intravenous thiamine, but the
majority will develop a chronic Korsakoff syndrome

Creutzfeldt-Jacob disease

- characterized by a rapidly progressive dementia,

myoclonus and distinctive electroencephalographic and
neuropathologic findings
- The infectious agent causing CJD is unique in being a
conformationally abnormal prion protein ie contains no
genetic material
- The dementia can be accompanied by signs of
involvement of any part of the central nervous system, but
myoclonus is particularly common.

Wernickes encephalopathy

- Although typically occurring sporadically in middle-aged

adults, a family history may be present in 8-10%.

- acute neuropsychiatric reaction to severe thiamine

deficiency.

- variant CJD in young adults has been linked with

exposure to beef infected with the bovine spongiform
encephalopathy agent. This new variant form often
presents with an extended neuropsychiatric prodrome with
mood disturbance or other psychiatric symptomatology.

- Characteristically patients are globally confused with gait

ataxia and ophthalmoplegia (nystagmus, abducens palsy or
conjugate gaze disorder are typical).

58

Secondary causes of dementia

- A score of 7 or more is indicative of normal memory and a

score of 4 and below indicate probable dementia. This is
useful for routine screening.

- Metabolic: thiamine deficiency, vitamin B12 deficiency,

hypothyroidism, Cushing's syndrome, Wilson's disease
- Vascular: Cerebrovascular disease, subdural haematoma
- Neoplastic: primary CNS tumours, metastases
- Inflammatory: SLE
- Drugs and toxins: Anticholinergics, heavy metal exposure
- Infection: Syphilis

Elderly Cognitive Assessment Questionnaire

MMSE

59

- This is the most widely used instrument for assessing

severity of the dementia. However it can only assess the
domains of cognitive deficit. The maximum score is 30. The
lower the score, the more severely demented the patient
is.

Geriatric Depression Scale

60

Clock drawing test

- A short 15-item questionnaire is used to assess the
depression in dementia. The patient has possible
depression if the score is 5 or more.

- This is used as a measure of constructional apraxia and

may also reflect frontal and temporoparietal functioning

Global Deteroration scale

- for staging of dementia

61

Stage 1
Stage 2

Stage 3
Stage 4
Stage 5

Stage 6
Stage 7

Normal
Very mild
Memory problem reported but not evident in
clinical interview.
Mild impairment in memory, concentration
and occupational performance
Moderate impairment in memory, knowledge
retrieval and complete tasks
Mod to severe impairment in recent and
remote memory, frequent disorientation to
time and place, impairments of ADL
Severe cognitive impairment with inability to
tend to ADL without assistance
Very severe impairment in cognition,
language and motor skills

Management of dementia

Eliminate non-essential drugs that could interfere

with cognition
Monitor driving ability and safety in use of household
appliances
Refer to local AD Association for information and
support groups
General treatment
o supportive medical care.
o emotional support for patient and family.
o Provide an environment that provides frequent
cues for orientation
o Supportive therapy & group therapy
Symptomatic treatment.

nutritious diet, proper exercise, attention to

visual and auditory problems.
Pharmacological treatment for specific symptoms.
o

Psychotropic treatment
Psychoeducation

- psychotherapeutic intervention
- educate the patient and their families about the illness,
the cause and course of the illness and the role of
medication
- helps improve patient's insight, compliance, lower rate of
relapse and better symptom control
- enhances support from family members

Cognitive Behavioural Therapy

- a way of talking about how you think about yourself, the

world and other people and how what you do affects your
thoughts and feelings
- helps to change how you think ('Cognitive') and what you
do ('Behaviour')
- focuses on the 'here and now' problems and difficulties.
62

- Instead of focusing on the causes of your distress or

symptoms in the past, it looks for ways to improve your
state of mind now.
- requires commitment and cooperation from the patient
- provides the patient with skills to approach future
problems
- make sense of overwhelming problems by breaking them
down into smaller parts:

A Situation - a problem, event or difficult situation.

From this can follow:
Thoughts
Emotions
Physical feelings
Actions

Thoughts:

Emotional:
Feelings
Physical:

Action:

Unhelpful

Helpful

He/she ignored
me - they don't
like me

He/she looks a bit

wrapped up in
themselves - I wonder
if there's something
wrong?
Concerned for the
other person, positive
None - feel
comfortable

Low, sad and

rejected
Stomach cramps,
low energy, feel
sick
Go home and
avoid them

Get in touch to make

sure they're OK

- indications

anxiety and panic disorders,

depression and bipolar mood disorders,

phobias (including agoraphobia and social phobia),

stress disorders,
bulimia,
obsessive compulsive disorder,
psychosis

Relaxation therapy

Deep breathing
- increases oxygen intake
- reduces tension
- Method:

Lie on your back with your feet slightly apart.

Breathe in slowly through your nose. Keep the tip of

your tongue gently touching the roof of your mouth.

Count to 5 as you inhale. Abdomen expands.

Hold the breath as you count to 5 again.

Exhale slowly with a whoosh of sound, count of 5.

Pause a second or two, then repeat.

Increase your counts from 5 to 10 when you are

more relaxed.

Progressive muscle relaxation

63

- Tensing and releasing groups of muscles one at a time to

relax your entire body.

Tense the muscles in your face (wrinkle your brow,

clench your teeth, open your mouth wide).

- Method:

When youve finished, lie quietly for a few minutes.

Your whole body should feel at rest.

Lie on your back.

Breathe in deeply.

Tense your entire body.

Hold the tension for few seconds, noticing how it

feels.

Then let go while exhaling, notice the difference.

Now tense each part of your body one by one,

starting with your feet.

- tricyclic antidepressant

Point your toes forward then up.

- amitriptyline, dosulepine, clomipramine, trazodone,

lofepramine, imipramine

Tense your calf muscles, then relax.

Move on to your thighs, then your stomach muscles.

Now arch your back slightly, then press it into the

floor.

Continue tensing individual muscle groups.

Make your hands into fists, then let go.

Press your arms against the floor, then relax them.

Shrug your shoulders, then release.

ANTI-DEPRESSANT

TCA

- indications: generalized anxiety disorder, panic disorder,

nocturnal enuresis, narcolepsy, eating disorders, chronic
pain
- side effects: arrhythmias, sedation, dry mouth, urine
retention
- contraindications: cardiac disease, patients with suicidal
intention

SSRI
- selective serotonin reuptake inhibitor

64

- fluoxetine, sertraline, paroxetine, citalopram, fluvoxamine

- moclobemide

- indications: depression, panic disorder, social phobia, OCD

- side effects: dry mouth, headache, insomnia

- side effects: stomach symptoms, sexual dysfunction,

restlessness, insomnia

Serotonin syndrome
- Life-threatening condition due to excessive serotonin

SNRI
- serotonin-noradrenaline reuptake inhibitor
- venlafaxine
- side effects: headache, somnolence, dry mouth

- Triad of changes in mental status, autonomic

hyperactivity and neuromuscular abnormalities
- Discontinue serotonergic agents, sedate with
benzodiazepine
- If fail give cyproheptadine

MAOI
- monoamine oxidase inhibitor

Types

Effects

Conclusion

- phenelzine, tranylcypromine, isocarboxazid

TCA & SSRI

Small increased
risk of minor
anomalies,
prematurity

Relatively safe
Discontinue close
to EDD to avoid
neonatal
withdrawal

MAOI

Teratogenic in
animals

AVOID

- indications: depression, anxiety disorders, eating

disorders, chronic pain
- side effects: dry mouth, postural hypotension, difficulty in
micturition, confusion
- precaution: opioid, avoid food rich in tyramine eg cheese,
liquor, liver

RIMA

ANXIOLYTICS

- reversible inhibitor of monoamine oxidase

65

Benzodiazepine

Benzodiazepine - temazepam, lormetazepam, flurazepam,

nitrazepam

- (short-term): alprazolam, clonazepam,

- (long-term): lorazepam, temazepam, diazepam
- indication: anxiety, panic disorder, insomnia
- Caution: effects of benzodiazepine can be potentiated by
fluvoxamine/alcohol, in patients with COPD

Cyclopyrrolone - zolpidem, zopiclone, zaleplon

Others - Chloral hydrate, Clomethiazole edisylate

- side effect: somnolence, risk of fall, respiratory

depression, dependence, risk of overdose due to tolerance
- Antidote: Flumazenil

Azapirone

ANTIPSYCHOTIC

- buspirone
- generalized anxiety disorder

Typical (1st gen)

Types

Effects

Conclusion

Benzodiazepines

Increased
risk of oral
cleft

Avoid if
possible in first
trimester

- dopamine antagonist
- haloperidol, flupenthixol, clopenthixol, fluphenazine,
chlorpromazine, thioridazine, pipothiazine, trifluoperazine

- side effects

HYPNOTIC

akathisia (restlessness; treat with Biperiden lactate),

acute dystonia (torticollis, tongue protrusions,
opisthotonos; treat with Orphenadrine),
parkinsonism (rigidity, coarse tremors; treat with
Benzhexol),
66

tardive dyskinesia (chewing, grimace)

Atypical (2nd gen)

- fluphenazine decanoate (25mg), flupenthixol decanoate

(20mg), zuclopenthixol decanoate (200mg), haloperidol
decanoate (5mg)(acute), pipothiazine palmitate,
risperidone (37.5mg)

- serotonin/dopamine antagonist
- lower risk of extrapyramidal syndrome

Anti-parkinsonian

- amisulpiride, sulpiride, olanzapine, quetiapine, sertindole,

ziprasidone, risperidone, zotepine, aripriprazole, clozapine

- biperiden, procyclidine, benzhexol, orphenadrine,

benztropine

- side effect: metabolic syndrome

- Clozapine

do not initiate in patients with history of

myeloproliferative disorder or clozapine-induced
agranulocytosis or granulocytopenia
upon initiation of therapy, monitor WBC weekly for 6
months followed by fortnightly for 6 months and
finally monthly
discontinue treatment if WBC <2000/mm3 or ANC
<1000/mm3
upon discontinuation, monitor WBC weekly for at
least 4 weeks from day of discontinuation or until
WBC >3500/mm3

Intramuscular injections

Types

Effects

Conclusion

st
1
generation

0.04% increased
risk of congenital
anomalies

Use in drug-nave
pregnant patients
rd
Taper in 3
trimester

nd
2
generation

Elevated rates of
GDM
Large-for-dates
babies

Depot

Prematurity and
small-for-dates
babies

Taper in 3
trimester

rd

Avoid if possible
Continue if risk of
discontinuation in
schizophrenic is
highly significant

MOOD STABILIZER

67

Carbamazepine

Sodium valproate

- indications: acute mania, bipolar disorder prophylaxis

- indications: acute mania, longer-term prophylaxis of

bipolar, mixed affective states

- side effects: drowsiness, ataxia, leucopenia

- side effects: tremor, sedation, tiredness, transient hair

loss
Lithium
- indications: acute mania, bipolar relapse prevention,
treatment-resistant depression
- contraindications: renal disease, cardiac disease,
pregnancy, lactation
- side effects: tremor, dry mouth, nephrogenic diabetes
insipidus, hypothyroidism
- becomes toxic in sodium-depleting states eg dehydration,
vomiting, diarrhea, renal impairment

Lamotrigine
- indication: bipolar depression
- side effects: maculopapular rash, headache, blurred vision

Gabapentin
- indication: treatment-resistant bipolar
- side effects: somnolence, dizziness, fatigue, nystagmus

- toxic syndrome

toxic encephalopathy causing delirium

cerebellar signs: Dysdiachokinesis, Ataxia,
Nystagmus, Intentional tremor, Slurred speech,
Hypotonia
treat with osmotic diuretics or haemodialysis

Types

Effects

Conclusion

Lithium

10% risk of
congenital
abnormality
Higher risk in
later trimesters

Fetal echo at 16-20

weeks if prescribed in
first trimester
Avoid in pregnancy

Sodium
valproate

Neural tube
defects
22% risk of
impaired

Avoid if possible in
women of
childbearing age
Folate 5mg/day 12
68

Lamotrigine

cognition

weeks prior to
conception

- contraindications: space-occupying lesion in the brain,

recent MI, arrhythmias, raised ICP, recent stroke,

Increased risk of
oral cleft

Slow reduction in
dosage over last
month with
reinstatement after
delivery

- side-effects: short-term retrograde amnesia, anterograde

amnesia, transient post-ictal confusion, status epilepticus,
headache
- The decision to initiate electroconvulsive therapy and the
number of treatment sessions on any patient in any
psychiatric hospital shall be made by a psychiatrist.

Preparation

PSYCHOSTIMULANTS

Effective and relatively

safe

Intravenous hydration

- caffeine, amphetamine, methylphenidate, cocaine

Both normal and high-risk

pregnancies
Careful attention to
obstetric and anaesthetic
factors

Elevation of patients right

hip

Low rate of ECT-related

complications and no
cases of premature labour

External fetal cardiac

monitoring

- indications: narcolepsy, ADHD, refractory depressive

disorder (combine with antidepressant), elderly depressed
with concomitant medical illness

ECT

Prescribing in pregnancy

- electroconvulsive therapy

- Antipsychotic therapy should be considered mandatory in

pregnant patients with psychotic features

- indications: severe depressive illness, catatonia,

prolonged/ severe manic episode

69

- When a planned or unplanned pregnancy occurs during

antipsychotic treatment, privilege the choice to continue
the previous therapy, if known as effective Pregnancy is not
the best period to experiment the effectiveness of drugs

Breastfeeding issues

- In the case of occurrence of psychotic symptoms in drugnave pregnant patients, privilege the drug showing the
highest number of reassuring reports and the lowest
reported number of fetal anomalies (eg, chlorpromazine)

- Reduced fetal withdrawal symptoms if psychotropes taken

antenatally

- Provide strict gynecological surveillance (tritest, regular

clinical follow-up, and ultrasound monitoring) during
therapy with both first-generation antipsychotics (FGAs)
and second-generation antipsychotics (SGAs)
- Provide strict endocrinological surveillance (Hb1Ac,
glycemia, cholesterol and triglycerides serum levels,
bodyweight gain) during therapy with FGAs but, especially,
with SGAs
- Take into consideration the possibility to taper both FGAs
and SGAs during the last trimester in order to reduce the
risk of neonatal extrapyramidal reactions and seizures
Match this decision with the risk of a relapse of psychotic
symptoms
- Provide strict cooperation between gynecologists,
neonatologists, and pediatricians in order to warrant
optimal maternal antenatal cares and promptly diagnose
and manage eventual perinatal complications during the
first hours after delivery

- All psychotropic medication passes into breast milk at 1%

of maternal serum level

- Avoid drugs or breastfeeding if baby is vulnerable

-

Premature
Renal/hepatic/cardiac/neurological impairment

- Close monitoring of babys behaviour

- Avoid sedating medications
- Time feeds to avoid peak levels

Symptoms of neonatal withdrawal

-

Irritability
Constant crying
Tremor
Poor feeding

- Provide regular follow-up of children exposed in utero to

either FGAS and SGAs in order to diagnose and manage
possible signs of neurodevelopmental delay
70

EPS and NMS

- sustained spasm of muscle or muscle groups causing

abnormal and uncomfortable posture

Extra pyramidal syndrome

- common examples: torticollis, uprolling of the eyeballs,

opisthotonus

- group of motor symptoms caused by antipsychotics

- treat by

- dopamine blockade in the nigrostriatal dopamine tract

causes an imbalance in the dopamine/acetylcholine
equilibrium resulting in motor disorders

stopping the antipsychotic or reducing the dosage

switching to a low EPS-producing antipsychotic
short term anticholinergics eg benzhexol, orally or
parenteral route

Akathisia
- subjective feeling of motor restlessness, observed
movements and inability to sit still

Parkinsonism

- treat by

- treat by

stopping the antipsychotic or reducing the dosage

switching to a low EPS-producing antipsychotic
short term benzodiazepine or beta blockers

- symptoms of bradykinesia, rigidity and resting tremors

stopping the antipsychotic or reducing the dosage

switching to a low EPS-producing antipsychotic
short term anticholinergics eg benzhexol, orally or
parenteral route

Tardive dyskinesia
- late onset involuntary abnormal movements
- may be irreversible

Dystonia

Neuroleptic Malignant Syndrome

71

- life-threatening
- early side effect due to antipsychotics
- clinical features: muscle rigidity, hyperpyrexia, autonomic
disturbances with elevated creatinine phosphokinase
- treatment

stop the antipsychotic

supportive management
bromocriptine (dopamine agonist) and dantrolene
(muscle relaxant)
ECT

72

Malaysian Psychiatry
Form 5:
Forms

Form 1:

Form 6:

Voluntary admission (if minor must be by guardian).

Indefinite duration

Form 2:

Convert voluntary admission to involuntary

detention
Valid for 1 month

Application by family to detain patient

Order by Medical Director/Head of Psychiatric

Department to detain
Valid for 1 month

Form 7:

Form 3:

Order by Medical Officer/Registered Medical

Practitioner to detain patient
Valid for 24 hours
Patient brought by police/welfare department officer

Order by 2 Medical Officers/Registered Medical

Practitioners and 1 Psychiatrist to continue detention
Valid for 3 months

Form 8:
Form 4:

Recommendation by Medical officer/Registered

Medical Practitioner to detain patient
Valid for 24 hours

Order by Board of Visitors to detain

Valid for 6 months

Form 9:

73

Order by Board of Visitors to continue detention

Valid for 1 year

Form 10:

8. Receive visitors
9. Have access to a second psychiatric opinion
10.Obtain legal representation and appeal to the Board
of Visitors or the Director General for discharge

Application by involuntary patient for discharge

Restraint or seclusion

Form 11:

Information to court of discharge of patient under

Section 55/73

Form 12:

Order to transfer patient from Psychiatric Hospital to

another Psychiatric Hospital by Director
General/Authorized Person

Patients Rights

1. The reasons of his admission and detention and

means of discharge, leave or transfer
2. Treatment, information, confidentiality, personal
identity, privacy
3. Adequate accommodation
4. Recreational activities
5. Practice gender identity
6. Practice religious belief of their choice
7. Communicate with persons outside

No minor patient below the age of twelve shall be

subjected to physical means of restraint or seclusion
in psychiatric hospitals.
The privacy and safety of a patient shall be observed
at all times during the restraint or seclusion
procedures.
No physical or chemical means of restraint or
seclusion shall be applied to patients in any
psychiatric nursing home or community mental
health centre, except during an emergency and the
patient shall then be transferred to psychiatric
hospitals without delay.
If the period of physical means of restraint of a
patient exceeds eight hours, a psychiatrist shall
review the patient on the need for further restraint.
No seclusion shall be carried out on a patient for
more than eight hours consecutively or for more
than twelve hours intermittently over a period of
forty eight hours, without an independent review by
a psychiatrist.

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Restraint area

There shall be a designated restricted area with a

dedicated observation bay manned by a qualified,
trained and experienced staff for the purpose of
monitoring of patients.
The area shall be adequately lit and ventilated.

Wire;
Bandage;
Equipment with tears, protruding metal parts or any
defect that may endanger patient.

Physical restraint

Indications for physical means of restraint

A restraint is for the purpose of the medical

treatment of the patient.
To prevent the patient from causing injury to himself
or any other person.
To prevent the patient from persistently destroying
property.
When other less restrictive method of treatment to
calm the patient has not been successful.

Equipment prohibited to be used as physical means of

restraint

Strings, ropes and raffia;

Handcuffs, shackles
Body restraint;
Strait jacket;
Chains (from whatever material);

Equipment that may be used as physical means of restraint

Restraint bed;
Restraint chair;
Padded restraints made of either calico cloth or
cotton , leather , nylon, vinyl , polyurethane, silicone
or rubber based materials; and
Any other equipment approved by the Director
General.

Application of physical means of restraint

carried out or supervised by qualified, trained and

experienced personnel
applied only to the limbs of a patient.
It shall not be necessary to obtain a persons
consent to the application of physical means of
restraint.

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No physical restraint is allowed in the psychiatric

nursing home and community mental health centre,
EXCEPT at the time of Transportation of patients to a
psychiatric hospital.
If the patient is acutely disturbed, a member of the
nursing staff shall visit at intervals of not more than
fifteen minutes.
A medical officer or registered medical practitioner
shall examine the acutely disturbed patient at
intervals of not more than four hours.

Removal of physical means of restraint

Decision to remove the restraints shall be made by

the psychiatric nurse on-duty.
The medical officer or registered medical practitioner
must be
informed of the termination of
restraints.

Seclusion

Indications for seclusion

Chemical restraint

Application of chemical means of restraint

Consent for chemical means of restraint consent

shall be obtained from a voluntary patient prior to
chemical means of restraint.
If the patient is acutely disturbed, a member of the
nursing staff shall visit at 15 minutes interval.
A medical officer or registered medical
practitioner shall examine the acutely
disturbed patient at intervals of not more than 4
hours.

A patient in a psychiatric hospital may be kept in

seclusion only if it is necessary for the protection,
safety or well-being of the patient or other persons
with whom the patient would otherwise be in
contact.
Other less restrictive method of treatment to calm
the patient has not been successful.

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Application of seclusion

It is not necessary to obtain a persons

consent for his seclusion to him or her.
A member of the nursing staff shall visit an acutely
disturbed patient at intervals of not more than
fifteen minutes.

A medical officer or registered medical

practitioner shall visit the patient under
seclusion at intervals of not more than four hours.
The patient may request to communicate with others
while under the seclusion.

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