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PSYCHIATRY

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Content

Title Page Number


Psychiatric Evaluation 2
Liaison Psychiatry 5
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

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Psychiatric evaluation
Perpetuating factor

what are the factors that may prevent him from getting better?
Knowing the patient
poor social support
Predisposing factor
poor pre-morbid level of functioning
why did the patient develop this disorder? poor insight
significant family history late treatment
personality disorder or traits co-morbid substance use
traumatic childhood experiences criminal record
chronic stress unemployment
substance use

Mental State Examination


Precipitating factor Appearance and behaviour
why develop at this point in time? Abnormal behaviour
Built
Cleanliness, consciousness, cooperation
Protective factor Distractibility, dressing
what are the factors that will help him recover? Eye contact
good social support Facial expressions
good pre-morbid level of functioning
good insight
early intervention Speech
no substance use including alcohol Language spoken
no criminal behaviour Adequate
Coherent
Relevant

2
Comprehension of speech Abstract reasoning and concrete thinking: explain a proverb,
similarities between table and chair
Mood and Affect
General knowledge: capital city of Malaysia, Independence Day
Current mood Judgment: in a burning house, burglar in the house
Labile mood Insight: awareness, attribution and acceptance of condition
Congruent affect

Physical examination
Thought content - to rule out medical causes for the symptoms
Delusions - to check for side effects from psychiatric medications
Obsessions
Concerns - to look for co-morbid medical disorders
Suicidal thoughts
Depressive thoughts
Phobias Multiaxial diagnosis

Axis I: Psychiatric disorder


Perception
Axis II: Developmental or personality disorder
Hallucinations
Illusions Axis III: General Medical condition

Axis IV: Presence of ongoing psychosocial stressors

Cognitive functions Axis V: Global Assessment of Functioning

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

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4
Liaison psychiatry - relationship between the psychological and physical aspects of the case

- patient's personality coping strategies

Classification of psychiatric illness encountered in liaison - patient's attitude towards psychiatric intervention
setting - staff attitude towards patient
- Psychiatry provoking ill-health

- Psychiatry as consequence of organic disease


Psychiatric disorder in physical illness
- psychiatric symptoms as presenting symptoms

- cerebral complications of organic disease


Factors affecting prevalence of psychiatric disorder in physical illness
- abuse of alcohol and drugs Illness
- deliberate self-harm symptoms
- sexual/relationship problems and eating disorders threat to life
course (acute, relapsing, chronic)
- psychiatric disorder exacerbate physical illness duration
- physical symptoms without organic basis disability
conspicuousness
- psychiatric and physical illness occurring by chance

Treatment
Liaison case summaries
nature
- reason for referral side-effects
- psychiatric diagnosis uncertainty of outcome
need for self-care
- physical disease and patient's reaction to it

- evidence of abnormal illness behaviour

5
Patient Implications for assessment
psychological vulnerability Characteristics of "at-risk" patients
social circumstances systematic review of patients, looking for psychiatric problems
other stresses (chronic and acute) presence of key symptoms
reactions of others information from relatives
implications for treatment

Factors associated with a particularly high risk of psychiatric problems


Severe illness Affective disorder

unpleasant - worsens prognosis of stroke and MI


threatening
acute relapsing or progressive illness
Positive psychological changes
- enhanced appreciation of life
Unpleasant treatment
- less concern for trivial or material things
major surgery
- more tolerance towards others
radiotherapy
chemotherapy - improved self-worth

Vulnerable patients Sick role


history of previous psychiatric problems - sick individual is obliged to seek the appropriate help, cooperate with
current psychiatric disorder assessment, accept a diagnosis and comply with the treatment
adverse social circumstances - legitimate adoption of this role requires sanction from relatives, medical
lack of personal and emotional support practitioners, employers and others in authority

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Illness behaviour Depression
- describes the actions of the patient and his attitude towards medical Risk factors for depressive disorders in physical illness
personnel - female gender
- eg stoical, restrained, histrionic, dramatizing, hostile, suspicious, - being unmarried
flirtatious, pleading, aloof, excessively cooperative and agreeable
- living alone

- previous depressive episodes


Abnormal illness behaviour
- certain medical treatments
- uncomfortable awareness of bodily events much of the time together
with excessive fears and concerns about health and disease - severe forms of physical illness

- relentless search for causes and cures coupled with inability to accept
reassurance from doctors even when this has been given clearly plus Depression in physically ill
appropriate investigation done
- co-morbid disorders continue after discharge
- inability to accept the suggestion that non-physical factors may be
relevant to one's condition - often goes undetected

- disability out of proportion to detectable organic disease - depressive disorders co-occurring with physical illness complicate
treatment of both disorders
- reinforcement of illness behaviour by family, disability payments and
health care providers - predicts readmission

- inappropriate response to physical disorder - either excessive disability - postponing treatment of depressive disorder worsens prognosis of both
or denial of need of treatment/limitation of activities
- high healthcare costs
- adoption of lifestyle around the sick role with repertoire of behaviours
- poor quality of life
to sustain sick role

7
Possible mechanism of co-morbidity Anxiety
- effect on neurotransmitters - causes increased vulnerability to cardiac events

- effect on immune system - phobic anxiety and generalised anxiety are predictors of MI and cardiac
death
- side effects of medications

- physical sequelae of suicide attempts


Anticipatory anxiety
- possible common genetic predisposition
- perpetuates the disability

Post-stroke depression
Organic anxiety syndromes
- up to 50% of patients develop post-stroke depression in acute post-
stroke period - cardiovascular system: angina, arrhythmia, congestive cardiac failure

- endocrine system: hyperthyroidism, phaeochromocytoma, menopause

Risk factors for post-stroke depression - metabolic disorders: hypoglycemia, hypoxia

- left anterior brain lesions (especially caudate nucleus) - neurologic disorders: seizure disorder, akathisia

- dysphasia - gastrointestinal system: peptic ulcer disease

- living alone - respiratory system: asthma, COPD

- past history of major depressive episodes - immunologic disorder: anaphylaxis, SLE

- previous history of psychiatric and/or cerebrovascular disorder

- family history of mood disorders

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Medications that cause anxiety-like symptoms Meaning of cancer to the patient

Stimulant intoxication: caffeine, nicotine, cocaine, - loss of physical strength and well being
methamphetamines, phencyclidine
- loss of independence
Sympathomimetics: pseudoephedrine, methylphenidate,
- loss of role
amphetamines, beta agonists
- loss of personal relationships
Dopaminergics: amantadine, bromocriptine, levodopa
- loss of life expectancy
Anticholinergics: benztropine, diphenhydramine, meperidine
- loss of control - the younger patient, the greater the impact
Miscellaneous: ephedrine, indomethacine, steroids

Drug withdrawal: alcohol, BDZ, opiates


Development of emotional problems

- no psychiatric disorder: 50%

- adjustment reaction: 30%


Cancer
- formal psychiatric diagnosis: 20%
- psychological impact of diagnosis depends on the way the disease
presents

- impact is greater if cancer is detected unexpectedly in an apparently Factors contributing to psychological problems
healthy person
- concern about prognosis and welfare of relatives
- uncertainty when patient first comes to clinic may be so stressful that
- poorly controlled physical symptoms eg pain, nausea, breathlessness
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

- metabolic disturbances such as liver failure

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- fear of being abandoned as the disease progresses Risk factors for anxiety

- lack of confiding relationships - harbouring underground fears about illness or its treatment and too
frightened to share with the staff
- other life events or difficulties not related to cancer
- seeks out more information than they can handle

- inaccurate information from non-medical professionals


Prevention of emotional problems
- personality
- offer information about illness and its treatment - may be repeated later

- allow the patient to express emotional distress


Effect of anxiety on cancer treatment
- provide ongoing care
- chronically anxious patients would consult doctors frequently and
become hypochondriacal once the diagnosis is confirmed
Detection of emotional problems
- false alarms about spread of disease
- simple screening questionnaire repeated at regular intervals
- very concerned about treatment and its side effects
- ask patient from time to time how they have been coping with the
- avoidance of treatment
emotional side of illness and let them discuss their current concerns
- may keep their symptoms a secret, resulting in a delayed diagnosis

- interfere with treatment and diagnostic test


Anxiety
- may be mixed with depression

- around time of initial diagnosis and while waiting for results for Denial
suspected relapse - unconscious refusal to acknowledge certain distressing aspects of reality

- to protect themselves from anxiety and unpleasantness in daily life

- usually lasts not more than a few days

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Suspect denial when Maladaptive denial

- reactions - delays cancer diagnosis

- looks for another physician in the hope of getting a "better explanation" - poor compliance

- asks for repeated investigations, partially knowing that the original - blocked communication with relatives
diagnosis is correct

- fail to realize their diagnosis/prognosis


Management of denial
- fails to ask questions about the illness
- Collusion
- forgets the information given
going along with the patient's view
- making unrealistic plans for the future kind to the patients but the staff feels uncomfortable
- understands the matters in intellectual sense without appropriate - Confrontation
emotional distress
challenging the patient with the truth
staff feels better but causes great distress to the patient
Adaptive denial - Middle approach
- denial acts as a buffer after unexpected news, allowing patient to collect ample opportunity for patient to ask questions but never forcing
himself and mobilize other resources unwanted information upon them
- 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

- 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)

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Anger Management of anger
- transient anger is a normal phase in the adjustment process - listen to patient, dont be defensive and dont make judgments
- some patients may obtain relief through the spontaneous free - offer consistent professional care although the patient is ungrateful
expression of anger before they move on towards acceptance
- facilitate a full blown expression of anger by a neutral counsellor
- family and nurses find it hard to cope because anger is displaced at all
directions and projected at random - responding to criticisms of other doctors and nurses

- anger can be more marked in the relatives - colluding with the blame on colleagues is unwise and unfair

- staff or family member should not react personally because it feeds into - encourage redirection of anger and re-chanelling the energy elsewhere
the patient's hostile behaviour eg exercise, music, creative activity and cancer-related charity work

- medication: psychotropics

Types of anger

- free floating: angry about the unfairness of the illness, blaming fate or Depression in cancer
God - usually associated with a great sense of loss
- displaced: towards healthcare staff - financial burden
- justified: delay in making diagnosis - loss of job due to frequent absences or inability to function
- suppressed: not co-operative and leads to depression - drugs: cytotoxics, steroids

Why anger?

- comparing self with others - limited activity

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

- loss of control

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Clinical presentation Management of depression

- physical symptoms seem to be out of proportion to the stage of cancer - let patient express their feelings of sadness and anger
progression eg weight loss, anorexia, fatigue
- foster a 'fighting' spirit, but if patient is very depressed, it can
- insomnia especially morning awakening accentuate the sense of shame and failure

- anxiety - if depression persists after simple discussion, more specialised


treatment such as psychotherapy and antidepressants will be required
- difficult to control pain

- suicidal thoughts
Acceptance
- a stage where the patient is neither depressed nor angry about his 'fate'
Types of depression
- almost void of feelings
- reactive depression
- as if the struggle is over
encouragements and reassurances
- patient prefers to be left alone
- preparatory grief
- not in a talkative mood
takes into account impending losses
- communications become more non-verbal than verbal
allow patient to express their sorrow

Effect on cancer treatment

- patient may consider themselves too worthless to get help

- they do not complain

- poor quality of life

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Personality Disorders Social learning in childhood for antisocial behavior

- through growing up in an antisocial family

CLUSTER A: Odd - through lack of consistent rules in the family

- learnt as a way of overcoming another problem

Paranoid - from poor ability to sustain attention and other impediments to learning

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


Borderline

Schizoid - Identity disturbance, intense unstable relationships, efforts to avoid


abandonment, recurrent suicidal behavior, transient stress-related
- Cold, detached, lack enjoyment, introspective paranoid ideation, impulsive, difficulty controlling anger, unstable affect,
history of conduct disorder before 15

Schizotypal

- socially anxious, cognitive and perceptual distortions, oddities of speech, Histrionic


inappropriate affective response, eccentric behaviour - Self-dramatization, suggestible, shallow and labile affect, seeks attention
and excitement, inappropriately seductive, over-concerned with physical
attractiveness, excessively impressionistic speech, considers relationships
CLUSTER B: Dramatic more intimate than they are

Antisocial Narcissistic

- Lack of concern for other's feelings, transient relationships, - Grandiose self-important, exploits others, requires excessive admiration,
irresponsible, impulsive and irritable, lack guilt and remorse, fail to learn envious and expects to be envied, lacks empathy
from adverse experience

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CLUSTER C: Anxious OTHERS

Avoidant Passive-aggressive

- feels socially inferior, preoccupied with possibility of rejection, avoids - Passive resistance when given demands for adequate performance
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 Depressive
inadequacy
- Persistently gloomy, strong sense of duty, little capacity for enjoyment,
unsatisfied with their life
Dependent

- Allows others to take responsibility, unduly compliant with wishes of Hyperthymic


others, feels unable to care for themselves, fear of being left to care for
themselves, difficulty initiating projects, goes to excessive lengths to - Habitually cheerful and optimistic, poor judgement, jumps to
obtain support, urgently seeks a supportive relationship conclusion, periods of irritability

Obsessive-compulsive Cycloid

- Preoccupied with details/rules, inhibited by perfectionism, over- - Extremes of depressive and hyperthymic personality disorders
conscientious, excessively concerned with productivity, rigid and
controlling, miserly, cannot discard worthless or worn-out objects

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Stress Disorders - symptoms

re-experiencing of the event


avoidance of stimuli that arouse recollections of the trauma
Acute stress reaction
marked symptoms of anxiety or hyperarousal
- Freeze, fight, flight significant distress or impaired social functioning
>3 of: sense of numbing/detachment, reduced awareness of
- Avoidance and denial should recede as anxiety diminishes to allow
surroundings, derealization, depersonalization, dissociative
coming to terms with the stressful experience
amnesia

Acute stress disorder Management


- onset while or after experiencing the distressing event - assess by acute stress disorder interview, acute stress disorder scale
- Lasts >2 days but <4 weeks - Critical incident stress debriefing: facts, thoughts, feelings, assessment,
- coping strategy: avoidance of reminders, use of alcohol or drugs education

- defence mechanisms: denial, displacement, regression -reassurance that the condition is frequent and short-lived

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


disrupted sleep)
Diagnosis
-Follow-up within 1 month
- stressor
- prevention: cognitive behavioural intervention 2-weeks post-trauma,
exposure to event involving actual/threatened death/serious prepare individuals 'at risk' (eg EMS and military) by training to remain
injury to self or others calm and objective, avoid identifying with victims, express emotional
experience of fear/helplessness/horror or disorganized/agitated reactions
behaviour in children

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PTSD - hyperarousal by >2 of

- traumatic event: experienced, witnessed or confronted with an event insomnia


that involved actual or threatened death or serious injury or a threat to irritability
the physical integrity of self or others poor concentration
hypervigilance
- etiology: fear conditioning, hypothalamic-pituitary-adrenal axis
exaggerated startle response
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 - assess by clinician-administered PTSD scale (gold standard) or post-
trauma, lower intelligence, lack of social support traumatic stress diagnostic scale

- significant distress or impaired social functioning for >1 month - management: counselling, CBT, if patient prefers or if psychotherapy
unavailable then give SSRI or TCA and continue for a year if good
- re-experience by >1 of
response
flashbacks
dreams
trauma re-enactment
distress or reactivity to cues resembling an aspect of the event

- avoidance of reminders by >3 of

thoughts
activities
inability to recall
reduced interest
'numbness'
restricted affect
sense of foreshortened future

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Childhood disorders - hyperactivity disorder: persistent of at least 6 months of > 6 symptoms
of

often fidgets with hands/feet or squirms in seat,


Attention-deficit/hyperactivity disorder often leaves seat in situations in which remaining seated is
expected,
often runs about or climbs excessively in situations in which it is
- pattern of diminished sustained attention and higher levels of inappropriate,
impulsivity in a child or adolescent than expected for someone of that age often has difficulty playing or engaging in leisure activities quietly,
and developmental level often "on the go" or acts as if "driven by a motor",
- more prevalent in boys often talks excessively

- attention-deficit disorder: persistent for at least 6 months of > 6 - some symptoms that caused impairment were present before 7 years
symptoms of old

- cognitive testing including a continuous performance task (the child is


failing to give close attention to details or makes careless
asked to press a button each time a particular sequence of letters or
mistakes in activities,
numbers flashes on the screen)
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
- first-line management: CNS stimulants methylphenidate and
chores,
dextroamphetamine
often has difficulty organizing tasks,
often avoids/dislikes/reluctant to engage in tasks that require - second-line management
sustained mental effort,
norepinephrine uptake inhibitor Atomoxetine,
often loses things necessary for tasks,
antidepressant venlafaxine,
often easily distracted by extraneous stimuli, often forgetful in
daily activities alpha-adrenergic receptor agonist clonidine

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Autism
- more frequent in boys

- qualitative impairment in social interaction, impairment in - associated with congenital rubella, phenylketonuria, tuberous sclerosis
communication, restricted repetitive and stereotyped patterns of - may be due to immunological incompatibility with mother (maternal
behaviour/interests antibodies directed at fetus) or perinatal complications
- due to neuroanatomical or biochemical factors

- onset < 3 years of age of delays or abnormal functioning in > 1 area - management: target behaviours that will improve their abilities to
(social interaction, language used in social communication, symbolic or integrate into schools, develop meaningful peer relationships and
imaginative play) increase the likelihood of maintaining independent living as adults

- total of > 6 items with


Rett's syndrome
>2 from qualitative impairment in social interaction

lack of eye contact, facial expression and gestures,


- progressive condition of developmental deterioration with onset after
no friends,
several months of apparently normal development
lack of social and emotional reciprocity
- apparently normal prenatal and perinatal development
> 1 from qualitative impairments in communication
- apparently normal psychomotor development through the first 5
delay or lack of development of spoken language,
months after birth
difficult to initiate and sustain a conversation,
stereotype and repetitive use of language or idiosyncratic - normal head circumference at birth
language

>1 of restricted, repetitive and stereotyped patterns of


behaviour/interest/activities

adherence to specific routines or rituals,


stereotyped and repetitive motor mannerisms

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- onset of all of the following after the period of normal development: >2 of qualitative social impairment

deceleration of head growth between ages 5 and 48 months, markedly abnormal non-verbal communicative verbal gestures,
loss of previously acquired purposeful hand skills between ages 5 failure to develop peer relationships,
and 30 months with the subsequent development of stereotyped lack of social or emotional reciprocity,
hand movements, impaired ability to express pleasure in other person's happiness
loss of social engagement early in the course,
appearance of poorly coordinated gait or trunk movements,
severely impaired expressive and receptive language >1 of restricted interest and patterns of behaviour
development with severe psychomotor retardation
preoccupation with one or more stereotyped and restricted
patterns of interest abnormal in intensity/focus,
apparently inflexible adherence to specific non-functional
- symptomatic management: physiotherapy for muscular dysfunction,
routines or rituals,
anticonvulsants for seizures, behaviour therapy and medication for
control of self-injurious behaviours stereotyped and repetitive motor mannerisms,
persistent preoccupation with parts of objects

Asperger's syndrome
- 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
- impairment and oddity of social interaction and restricted interest and
behaviour - no language delay, cognitive delay or adaptive impairment

- no significant delays occur in language, cognitive development or age-


appropriate self-help skills
- 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

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Oppositional defiant disorder - management:

family intervention using both direct training of the parents in


child management skills and careful assessment of family
- a child's temper outbursts, active refusal to comply with rules and interactions,
annoying behaviours exceed expectations for these behaviours for individual psychotherapy where the child is exposed to a situation
children of the same age with an adult to practice more adaptive responses,
- in the absence of serious violations of social norms or of the rights of self-esteem must be restored before a child with oppositional
others defiant disorder can make more positive responses to external
control
- classic psychoanalytic theory implicates unresolved conflicts as fuelling
aggressive behaviours targeting authority figures
Conduct disorder

- pattern of negativistic, hostile and defiant behaviours lasting >6 months


with presence of >4 symptoms of
- set of behaviours that evolves over time, usually characterized by
often losing temper, aggression and violation of the rights of others
often arguing with adults,
- associated with many other psychiatric disorders including ADHD,
often actively defies or refuses to comply with adult's requests or
depression and learning disorders
rules,
often deliberately annoys people, - also associated with certain psychosocial factors such as harsh punitive
often blames others for their mistakes/misbehaviour, parenting, family discord, lack of appropriate parental supervision, lack of
often touchy or easily annoyed by others, social competence, low socioeconomic level
often angry and resentful,
- average age of onset is 10-12 in boys and 14-16 in girls
often spiteful or vindictive
- repetitive and persistent pattern of behaviour in which the basic rights
of others or major age-appropriate societal norms or rules are violated
- 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

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- presence of >3 criteria in past 12 months with >6 months of at least one - mild: few if any conduct problems in excess of those required to make
criteria of the diagnosis and conduct problems cause only minor harm to others

aggression to people and animals - moderate: number of conduct problems and effect on others
intermediate between mild and severe
bullies/threatens/intimidates others,
initiates physical fights, - severe: many conduct problems in excess of those required to make the
used a weapon that can cause serious physical harm to others, diagnosis or conduct problems cause considerable harm to others
physically cruel to people/animals,
stolen while confronting a victim,
forced someone into sexual activity, - good prognosis is predicted for mild conduct disorder in the absence of
coexisting psychopathology and the presence of normal intellectual
destruction of property functioning
deliberately engaged in fire setting with the intention of causing - those with severe conduct disorder are most vulnerable to comorbid
serious damage, disorders later in life such as mood disorders and substance use disorders
deliberately destroyed others' property,

deceitfulness or theft
- management:
broken into someone else's house/building/car,
lies to obtain goods or favours or to avoid obligations, multimodal treatments using behavioural interventions where
stolen items of nontrivial value without confronting a victim, rewards are earned for prosocial and nonaggressive behaviours,
social skills training,
serious violations of rules family education and therapy
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

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Eating disorders Types

- restricting type: during current episode there was no regular binge-


eating or purging behaviour
Anorexia nervosa
- purging/binge-eating type: during current episode there was regular
- self-induced starvation due to a relentless drive for thinness/morbid fear binge-eating or purging behaviour.
of fatness resulting in medical signs and symptoms of starvation

- behaviours and psychopathology are present for at least 3 months


Complications
- usually occurs between 10-30 years old
- from weight loss
- associated with disturbances of body image, the perception that one is
distressingly large despite obvious thinness loss of fat/muscle mass, reduced thyroid metabolism (low T3),
difficulty maintaining core body temperature
- co-morbidities include depression, social phobia and OCD loss of cardiac muscle, small heart, cardiac arrhythmias,
bradycardia, sudden death
- starvation results in suppressed thyroid function, hypercortisolemia,
delayed gastric emptying, bloating, constipation, abdominal pain
amenorrhea
amenorrhea, low LH and FSH
lanugo, edema
- refusal to maintain body at or above a minimally normal weight for age leucopenia
and height (body weight <85% of expected) abnormal taste sensation, apathetic depression, mild cognitive
disorder
- intense fear of gaining weight or becoming fat even though underweight osteoporosis
- disturbance in the way in which one's body weight or shape is - from purging
experienced, undue influence of body weight or shape on self-evaluation,
or denial of the seriousness of the current low body weight electrolyte abnormalities, seizures, mild neuropathies, fatigue
and weakness, mild cognitive disorder
- amenorrhoea (absence of >3 consecutive menstrual cycles) in post- salivary gland and pancreatic inflammation and enlargement with
menarcheal females increase in serum amylase, esophageal and gastric erosion,
dysfunctional bowel with haustral dilation

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erosion of dental enamel (especially of front teeth) with - admission to hospital is indicated if
corresponding decay
the patient's weight is dangerously low
there is severe depression and suicidal risk
outpatient care has failed
- the disorder may run a chronic course but recovery can occur even after
many years

- indicators of favourable outcome: admission of hunger, lessening of Bulimia nervosa


denial and immaturity, improved self-esteem
- eating, in a discrete period of time, an amount of food that is definitely
- usual causes of death are suicide or as a direct result of medical larger than most people would eat
complications
- a sense of lack of control over eating during the episode

- recurrent inappropriate compensatory behaviour in order to prevent


Management weight gain
- behavioural, interpersonal and cognitive approach, comprehensive
treatment plan involving both individual and family therapy
Types
- 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 - purging: regularly engages in self-induced vomiting or the misuse of
of what her weight should be laxatives, diuretics or enemas

- monitor the patient's physical state regularly and prescribe vitamin - non-purging: uses other inappropriate compensatory behaviours such as
supplements if indicated excessive exercise, but has not regularly engaged in self-induced vomiting
or the misuse of laxatives, diuretics or enemas
- 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
- usually of normal weight
patient does not induce vomiting or take purgatives
- most are female and often have normal menses

- onset in late adolescence, often following a period of concern about


shape and weight

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- some may have a history of a previous episode of anorexia nervosa - antidepressant drugs such as SSRIs decrease the frequency of binge
eating and purging and improve mood
- there is an initial period of dietary restriction which, after a variable
length of time, breaks down with increasingly frequent episodes of - the patient is more likely to wish to recover and a good working
overeating relationship can often be established

- as the overeating becomes more frequent, the body weight returns to a there is no need for weight restoration
more normal level
- it is necessary to assess the patient's physical state and to measure
- episodes of bulimia may be precipitated by stress or the breaking of self- electrolyte status in those who are vomiting frequently or misusing
imposed dietary rules, or may occasionally be planned laxatives

- voracious eating at first brings relief from tension but relief is soon
followed by guilt and disgust
Binge eating disorder

- recurrent bulimic episodes in the absence of other diagnostic features of


Complications bulimia nervosa, particularly counter-regulatory measures
- repeated vomiting leads to potassium depletion, resulting in weakness, - patients may have depressive symptoms and some dissatisfaction with
cardiac arrhythmia and renal damage their weight and shape, however the latter are usually less severe
- teeth become pitted by acidic gastric contents - 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
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

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Substance abuse
Substance dependence: maladaptive pattern of substance use leading to
clinically significant impairment and developing within 12 months >3 of:
Abuse and dependence
tolerance: defined as need for markedly increased amounts to
achieve desired effect/ markedly diminished effect with
continued use of same amount
Substance abuse: maladaptive pattern of substance use leading to
withdrawal manifested as characteristic withrdwal of the
clinically significant impairment and developing within 12 months >1 of:
substance/ the same substance is taken to relieve or avoid
recurrent substance use resulting in a failure to fulfil major role withdrawal symptoms
obligations at work/ school/ home the substance is taken in larger amounts or over a longer period
recurrent substance use in situations in which it is physically than intended
hazardous persistent desire or unsuccessful efforts to cut down substance
recurrent substance-related legal problems use
continued substance use despite having persistent or recurrent great deal of time spent in activities necessary to obtain the
social or interpersonal problems caused or exacerbated by the substance or recover from its effects
effects of the substance 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

26
Alcohol stupor

Excessive consumption of alcohol: weekly intake of alcohol exceeding 21 Aetiology: genetic factors, abnormalities in alcohol dehydrogenase
units for men and 14 units for women leading to less sensitivity to acute intoxication effects, learning factors,
personality factors (risk taking, novelty seeking, chronic anxiety)

Alcohol misuse: drinking that causes mental, physical or social harm to an


individual Alcohol withdrawal:

- cessation of/ reduction in heavy/ prolonged alcohol use

CAGE questionnaire - significant impairment in social/ occupational functioning

Have you ever felt you ought to Cut down on drinking? - >2 of
Have people Annoyed you by criticizing your drinking? automomic hyperactivity,
Have you ever felt Guilty about your drinking? hand tremors,
Have you ever had a drink first thing in the morning as an Eye- insomnia,
opener to steady your nerves or get rid of a hangover?
nausea,
>2 positive replies implies alcohol misuse
transient visual/ auditory/ tactile hallucination,
psychomotor agitation,
anxiety,
Alcohol intoxication:
grand mal seizures
- recent ingestion of alcohol

- clinically significant maladaptive psychological or behavioral changes


- 6-8 hours after drinking: tremors in hands/legs, agitation, nausea,
- >1 of insomnia

slurred speech, - 8-12 hours after drinking: misperceptions and hallucinations


incoordination, - 12-24 hours after drinking: seizure
nystagmus,
impairment in attention or memory, - during 72 hours: delirium tremens

27
Alcohol dependence: >3 for 12 months Biological dysfunction

- tolerance, direct toxic effect on brain and liver


poor diet causing vitamin B and protein deficiency
- withdrawal,
accidents and falls
- taking larger amounts over longer period of time than intended, general neglect of hygiene
fetal alcohol syndrome
- persistent desire or repeated unsuccessful efforts to cut down or
peripheral neuropathy, dementia, cerebellar degeneration
control,
gastritis, liver damage, acute/chronic pancreatitis
- great deal of time spent in activities necessary to obtain the severe muscle wasting, osteoporosis, osteomalacia
substance/use/ recover from its effects, increased BP, increased stroke risk
- important social/ occupational/recreational activities given up or anemia, myopathy
reduced,

- continued use despite knowledge of persistent/recurrent Psychological dysfunction


physical/psychological problem likely to have been caused/exacerbated
by the substance 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,
Problem drinking: drinking has caused an alcohol-related disorder or regular episodes - frequent heavy drinking, prolonged episodes -
disability sustained excessive drinking
delirium tremens: MEDICAL EMERGENCY
Wernicke's encephalopathy: due to thiamine deficiency, delirium
Social dysfunction + ophthalmoplegia+ nystagmus + ataxia, treat with pabrinex or
benzodiazepine
family: domestic violence/neglect Korsakoff's syndrome: retrograde and anterograde amnesia due
accidents: DUI to thiamine deficiency, confabulation
work problems: absconding, poor performance Alcoholic dementia: intellectual impairment due to prolonged,
crime: assault, rape heavy intake of alcohol
decision making: unprotected sex, illicit drugs, body modifications transient hallucinations: during withdrawal

28
alcoholic hallucinosis: distressing auditory hallucinations which total abstinence vs controlled drinking
may be followed by persecutory delusions, happens when normal prevent major complications of withdrawal
blood alcohol levels drop, responds to antipsychotics group therapy, couple therapy, cognitive-behavioural therapy
cerebellar degeneration - severe limb ataxia + dysarthria + slurred
speech + nystagmus due to toxic effect on Purkinje cells of
cerebellar cortex Abstinence maintenance:
Marchiafava-Bignami syndrome: demyelination and necrosis of
middle 2/3 of corpus callosum disulfiram: blocks oxidation of alcohol causing acetaldehyde
depressive disorder accumulation, anticipation of unpleasant reaction deters from
impulsive drinking
pathological jealousy
sexual dysfunction acamprosate: stimulate inhibitory effect of GABA and decrease
excitatory effect of glutamate, to remain alcohol-free after
detoxification
naltrexone: reduce craving, short-term treatment
Delirium tremens

24-48 hours after stopping heavy, prolonged drinking,


delirium, Prevention:
coarse tremors
raise awareness
sympathetic overdrive increase heart rate and BP,
change level of drinking: economic control, formal control
electrolyte disturbance,
(licensing laws), informal control (customs and moral beliefs)
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

29
Recreational drugs - (in pregnancy) low birth weight, small head circumference, early
gestational age, growth retardation

- (psychological) restlessness, dysphoria, irritability, insomnia, hostility,


Amphetamine confusion, paranoid delusions, hallucinations, anxiety

Amphetamine and similar substances: Amphetamine intoxication:


- MDMA (ecstasy), LSD, ketamine, Rohypnol - recent use of methamphetamine or a related substance

- clinically significant maladaptive behavioral or psychological changes


Amphetamine use: - >2 of
- taken orally, snorted, injected tachycardia or bradycardia
pupillary dilation
- Symptoms: Elation, euphoria, friendliness, decreased fatigue, induction
increased or lowered blood pressure
of anorexia, heightened pain threshold, increased self-confidence,
increased sensory sensitivity perspiration or chills
nausea or vomiting
- lasts 4 to 8 hours evident weight loss
- detectable for 4 days psychomotor retardation or agitation
muscular weakness/ respiratory depression/ chest pain/ cardiac
arrhythmias
Amphetamine side effects confusion/ seizures/ dyskinesias/ dystonias/ coma

- (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

30
Amphetamine withdrawal: Cannabis
- cessation of/ reduction in amphetamine use that has been heavy or
prolonged
Cannabis and similar substances:
- dysphoric mood and >2 of
- marijuana, grass, weed, pot, tea, Mary Jane, hemp, chasra, bhang, ganja,
fatigue dagga, sinsemilla
vivid unpleasant dreams
insomnia or hypersomnia - smoked
increased appetite
psychomotor retardation or agitation
Cannabis intoxication:

- recent use of cannabis


Management:
- clinically significant maladaptive behavioural or psychological changes
- diazepam for agitation and hyperactivity,
- within 2 hours develops >2 of
- bupoprion for withdrawal
conjunctival injection
increased appetite
Amphetamine-induced psychotic disorder: dry mouth
tachycardia
- Symptoms: paranoia, predominant visual hallucinations, appropriate
affect, hyperactivity, hypersexuality, confusion and incoherence

- treatment: short-term haloperidol 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

31
- (long-term) cerebral atrophy, lowered threshold for seizure, - (life-threatening) non-haemorrhagic cerebral infarctions, seizures,
chromosomal damage, birth defect, impaired immune reactivity, myocardial infarctions, arrhythmias, respiratory depression
alteration in testosterone concentration, dysregulation of menstrual cycle

Cocaine intoxication:
Cocaine
- recent use of cocaine

- clinically significant maladaptive behavioural or psychological changes


Cocaine and similar substances: - >2 of
- rocks (crack) tachycardia or bradycardia
- injected, smoked, snorted, inhaled pupillary dilation
elevated or lowered blood pressure
perspiration or chills
Cocaine use: nausea or vomiting
evident weight loss
- alert, euphoria, sense of well-being, heightened self-esteem, decreased
psychomotor agitation or retardation
hunger, less need for sleep, improved mental and physical tasks
muscular weakness/ respiratory depression/ chest pain/ cardiac
- lasts for 30-60 minutes arrhythmias
confusion/ seizures/ dyskinesias/ dystonias/ coma
- 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,

32
Cocaine withdrawal: Hallucinogens
- cessation of cocaine use that has been heavy and prolonged

- 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 Hallucinogen use:
increased appetite - tablets, blotter acid
psychomotor retardation or agitation
- symptoms: increased deep tendon motor reflexes, increased muscle
tension, ataxia, increased respiration, increased blood pressure,
decreased appetite, salivation, synesthesia, visual hallucinations, intense
Cocaine-induced psychotic disorder symptoms:
transient emotions, increased suggestibility
- paranoid delusions, auditory hallucinations, formication, grossly
- lasts 8 to 12 hours
inappropriate sexual and generally bizarre behaviour
- treatment: diazaepam (20mg oral)

Hallucinogen side effects:

- (biological) tremors, tachycardia, hypertension, hyperthermia, blurring


of vision, mydriasis

- (psychological) chronic anxiety, depression

33
Hallucinogen intoxication: Opioid
- recent use of a hallucinogen

- clinically significant maladaptive behavioural or psychological changes Opioid and similar substances:
- perceptual changes occurring in a state of full wakefulness and alertness - 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,
palpitations dry mouth, itchy face, facial flushing

blurring of vision

tremors Opioid side effects:

incoordination - respiratory depression, pupillary constriction, smooth muscle


contraction, constipation, changes in blood pressure/ heart rate/ body
- treatment: antipsychotics, lithium, carbamazepine temperature

Hallucinogen Persisting Perception Disorder: Opioid intoxication:


- symptoms: re-experiencing of perceptual symptoms experienced while - recent use of an opioid
intoxicated following cessation of use, spontaneous, transitory
- clinically significant maladaptive behavioural or psychological changes
- comorbidities: panic disorder, major depression, alcohol dependence
- pupillary constriction and >1 of

drowsiness or coma
slurred speech
impairment in attention or memory

34
Opioid withdrawal symptoms:

- 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
fever
insomnia

- onset within 8-12 hours after last dose, peak at 24-48 hours and
subsides over 10 days

Treatment

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 well-recognised cause of


fits together with the altered behaviour.

35
Schizophrenia, depression and bipolar mood disorder Types

- paranoid: persecutory delusions with auditory hallucinations

Schizophrenia - disorganized: disorganised behaviour with disorganized speech and


affective blunting
- >2 of
- catatonic: presence of 2 or more of
delusions
motor immobility,
hallucinations
catatonic excitement,
disorganized speech
repetitive behaviour or speech
disorganized or catatonic behaviour
negative symptoms - simple: insidious development of odd behaviour, social withdrawal and
declining work performance
- 1 month of symptoms + 5 months of residual symptoms
- undifferentiated: equally prominent features of >1 type

- residual: chronic schizophrenia >1 year with persistent negative


Negative symptoms
symptoms but no recurrence of positive symptoms
alogia
affective flattening
avolition Depression in schizophrenia is due to
anhedonia
part of schizophrenia, remits with psychosis
attention reduced
recovery of insight into nature of illness and future problems
side-effect of antipsychotics

Schneider's Positive symptoms

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

36
Good prognostic indicators for schizophrenia Schizophreniform psychosis
Female >2 of
Late onset
Good premorbid level of functioning delusions
No family history hallucinations
Acute onset disorganized speech
Prominent positive symptoms disorganized or catatonic behaviour
Good social relationships negative symptoms
Duration of untreated psychosis is less than a year

- lasts >1 month but <6 months


Brief psychotic disorder

- >1 of Treatment- resistant schizophrenia


delusions - patient continues to experience psychotic symptoms in spite of trying a
hallucinations number of antipsychotics of the typical and atypical group in sufficient
disorganized speech dose for an adequate trial period
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.

- During the same period of illness, there have been delusions or


hallucinations for at least 2 weeks without prominent mood symptoms.

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


depressive episode)

37
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 - moderate: worse in the morning, neglected grooming
observed psychomotor agitation or retardation - severe: inattention to basic hygiene and nutrition, complete loss of
fatigue or loss of energy social/ occupational function
feelings of worthlessness or guilt
diminished ability to think or concentrate
recurrent thoughts of death or suicidal ideation Dysthymia
- present >2 weeks - chronic depressive state

Depression with psychosis Cyclothymia


- as above + presence of delusions or hallucinations on worthlessness, - persistent instability of mood with episodes of mild elation/ mild
guilt or ill-health depression

Atypical Differential diagnosis:


- variably depressed mood with mood reactivity to positive events - Bipolar
- Adjustment disorder
- overeating/ oversleeping
- Dysthymic disorder with long-standing symptoms
- extreme fatigue and heaviness in limbs - Depression due to general medical condition
- Medication/illicit drug use
- pronounced anxiety
- Menopause
- Post-partum blues/depression

38
Management - Duration of treatment

- Psychotherapy 1st episode: 6 9 months after remission


2nd episode: continue antidepressants 2 3 years after remission
Counselling
3rd episode: lifelong
Problem solving
CBT

- Pharmacotherapy Counselling for treatment

SSRI Anti-depressants may take 2-4 weeks for visible effects but must
TCA be taken continuously without stopping
Start with low dose but may have to increase dose for optimal
- Insomnia
response
SSRI sedative eg Fluvoxamine, sertraline Benzodiazepine is for short-term, will need to be stopped once
TCA amitriptyline, imipramine the anti-depressants begin to work
Sleep hygiene The anti-depressants must be taken for at least 6 months (in first
episode of depression)
- Add benzodiazepine There may be a relapse after which the duration of treatment will
If patient is anxious with no history of adverse effects with be longer
benzodiazepine, esp when using SSRI The medication needs to be tapered down gradually. Avoid
First 2 weeks of SSRI use can cause paradoxical anxiety abruptly stopping medication (to avoid SSRI discontinuation
syndrome)
- Indications for ECT

Life-threatening condition eg refusal to eat or high suicidality


Moderate or severe depression for short-term therapeutic Treatment-resistant
benefits - Failed to response to >2 antidepressant treatments at an
Psychotic depression adequate dose for an adequate duration of at least 4 weeks
Treatment resistant - Treat by switching to another antidepressant (either from the
Poor response/intolerance to medication same class or different class), augment with lithium/olanzapine,
High degree of symptom or functional impairment combine with another antidepressant

39
Depression in elderly Baseline investigations before starting therapy (FBC, RBS, lipid
profile, RP, LFT, ECG)
- Declining senses/cognitive deficit/sexual changes
- Medical cause: Distress due to illness/side effect of medication/
painful procedures/dependency
Indications for admission
- Social cause: Retirement, multiple bereavements, empty nest
syndrome, isolation/loneliness, physical/emotional abuse, Risk of harm to self
vagrancy Psychotic symptoms
Inability to care for self
Lack of impulse control
Suicide risk Danger to others
S Sex (male)/single/separated/divorced/widowed/schizophrenia
U Unemployment SAD PERSONS SCALE risk assessment
I Illicit drug use
Sex
C Chronic medical condition with poor symptom control Age
Depression
I Inheritance (Family history of suicide)/intend to die
Prior history
D Depression Ethanol abuse
A Attempted before/anxiety disorder/age >40 Rational thinking
Support system loss
L Life event Organized plan
No significant other
Sickness
Investigations
- 0-2 no real problem
TFT, VDRL, ESR
Urine screening for drugs esp amphetamine-type stimulants - 3-4 send home but check frequently
CT brain if focal neurological deficit present/suspected SOL - 5-6 consider hospitalization if assured that patient will return for review
EEG suspected seizure disorder
- 7-10 definitely hospitalization

40
Bipolar mood disorder excessive involvement in pleasurable activities with painful
consequences
Typical age of onset is 21 years

Mixed: both mania and major depressive episode >1 week


Mania

- persistent elevated or irritable mood >1 week


Rapid cycler: >4 mood swings in 1 year
- >3 of

grandiosity
decreased need for sleep Treatment for mania
pressured speech sodium valproate,
flight of ideas olanzapine,
distractible chlorpromazine,
goal-oriented activity haloperidol,
excessive involvement in pleasurable activities with painful quetiapine,
consequences aripiprazole,
risperidone,
ECT
Hypomania

- persistently elevated or irritable mood >4 days


Treatment for depression
- >3 of
SSRI Fluvoxamine
grandiosity Lamotrigine,
decreased need for sleep Lofepramine (AVOID if suicidal),
pressured speech ECT
flight of ideas
distractible
goal-oriented activity

41
Maintenance Factors predicting a greater risk of future episodes

lithium, Incomplete symptomatic remission


carbamazepine (esp rapid-cycling) Early age of onset
lamotrigine Poor social support
Poor physical health
Comorbid substance misuse
High risk clinical factors for suicide include: Comorbid personality disorder

Severe insomnia - interval between episodes becomes progressively shorter with both age
Self neglect and the number of episodes
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.

42
Suicide and Deliberate Self-harm Reasons for higher suicide rates in men

Men are less likely to seek help for emotional problems.

Suicide Men are more impulsive than women.

Men are less socially embedded than women.

Risk factors for suicide Men may choose more lethal methods

Patient demographics: increasing age and male gender

Past and current suicidality (50% more likely) Risk factors for suicidal behaviours in women

Psychiatric diagnosis and psychiatric symptoms Intimate partner/spouse abuse

Individual history: Medical history, family history, psychosocial Gender inequalities in some society/within the family.
history
Severe psychiatric illness following delivery e.g. postpartum
Personality strengths and weaknesses. depression and postpartum psychosis.

Reasons for higher suicidal behaviours in the elderly Characteristics of past attempts that increases future risk
Less physical resilient: suffering from physical illness. Presence of longstanding medical problems
More likely to have access to medication: overdose Psychiatric illness esp depression, alcohol abuse
Poverty and isolation: less likely to be rescued Social isolation / poor support
Generally demonstrate a greater determination to die as they Past attempt with adverse consequences e.g. disability
give few warning signs
high intent
Involve greater planning and use more lethal methods.
Use of highly lethal means

Measures taken to avoid discovery

43
Risk of successful suicide in current suicidal ideation Psychiatric symptoms associated with suicide

the magnitude of suicidal thoughts is greater and persistent. Mood disorder esp depression

The intent is higher (patients expectation to die) hopelessness

Detailed and specific suicide plan Psychotic disorder with command hallucinations

Impulsivity

Aspects of suicide plan associated with higher lethality aggression

Method: higher lethality method is associated with higher suicide Panic disorders
risk.
Personality disorders
Patients belief about the lethality of the method (high intent) Substance abuse and dependence
Low chance of rescue Anger
Steps taken to enact plan: hoarding pills, plan the time and Side effects of Rx e.g., akathisia
setting, ensuring isolation and low chance of discovery.
higher risk is associated with individuals who are also socially
Preparedness of death: making a will, writing letters to loved isolated, with maladaptive coping and experiencing significant
ones, suicide notes. loss (e.g. financial)

Protective factors for suicide

Optimism
Religiosity
High life satisfaction

44
Deliberate Self-Harm Management

Psychoeducation
Cognitive behavioural therapy
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

Reasons for deliberate self-harm

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

Specific questions in assessment of the patient

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?

45
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 non-conflictual threat - With or without agoraphobia

- can be due to

Anxiety is a response to a threat that is unknown, internal, vague, or dysfunction of noradrenergic neurons of the locus ceruleus,
conflictual panic-inducing substances,
pathological involvement in the temporal lobes,
classic conditioning or from parental behaviour,
Panic disorder unsuccessful defences against anxiety-provoking impulses

- management: CBT, relaxation therapy, exposure therapy,


- Recurrent unexpected panic attack antidepressants, benzodiazepine
- 4 or more of

palpitations, Agoraphobia
sweating,
trembling,
SOB, - anxiety about being alone in situations or places which are perceived as
chest pain, being difficult to get help if a subsequent panic attack occurs
air hunger,
dizzy,
derealization, - Marked and consistently manifests fear in or avoidance of >2 of
nausea,
numbness, crowds,
chills public places,
traveling alone
- Persistent concern of future attacks traveling away from home

46
- >2 anxiety symptoms present together in the feared situation on at least - >2 anxiety symptoms manifested at some time since the onset of the
1 occasion since the onset of the disorder and 1 of the symptoms are disorder together with >1 of

autonomic arousal symptoms (palpitations, sweating, dry mouth), blushing/shaking,


symptoms involving chest and abdomen (difficulty breathing, fear of vomiting,
feeling of choking, chest pain, nausea), urgency or fear of micturition or defecation
symptoms of mental state (dizzy, derealization, fear of losing
- Significant emotional distress is caused by the symptoms or by the
control, feat of dying)
avoidance, and the individual recognizes that these are excessive or
general symptoms (hot flushes or cold chills, numbness)
unreasonable
- significant emotional distress caused by avoidance or by the anxiety
- Symptoms are restricted to, or predominate in, the feared situations or
symptoms
contemplation of the feared situations
- symptoms are restricted to or are predominant in the feared situations
- due to conditioning, excessively high standards for social performance,
or contemplation of the situation
negative beliefs about self, excessive monitoring of their own
performance in social situations

- management: antidepressants, anxiolytics, CBT


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 of being the focus of
attention/situations where there is fear of behaving in a way that will be
- Marked and persistent fear or avoidance of a specific object that is
embarrassing
excessive or unreasonable

- exposure to the phobic stimulus almost invariably provokes an


immediate anxiety response

- phobic situation is avoided

47
- Recognition that the fear is excessive or unreasonable Generalized anxiety disorder
- Symptoms restricted to the feared situation or contemplation of the - Excessive anxiety and worry about a number of events or activities
feared situation (future oriented), occurring more days than not for at least 6 month
- due to persistence of childhood fears, conditioning, stimulation in the - Worry is difficult to control
anterior cingulate cortex/amygdala/hippocampus
- Worry is associated with >3 of

restlessness,
- management: exposure, benzodiazepines for short term relief easily fatigued,
difficulty concentrating,
irritability,
Obsessive-Compulsive disorder muscle tension,
sleep disturbance

- Anxiety and worry cause significant impairment in occupational, social


- Obsessions: recurrent and persistent thoughts, impulses, or images that
or other daily functioning
are experienced as intrusive and inappropriate

- Compulsions: repetitive behaviors or mental acts whose goal is to


prevent or to reduce anxiety or distress - management: CBT, SSRI Sertraline or escitalopram, Propanolol, TCA,
Benzodiazepine
- Recognition that the fear is excessive or unreasonable

- 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)

48
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

- 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

49
Pregnancy-related depression - Disinterest in the newborn / fearful of being left alone with the baby.

- Increased risk of suicide, neglect of the newborn and infanticide

Depression during pregnancy - Treatment includes antidepressants Fluoxetine (SSRI) or Dothiepin


(TCA), ECT and psychotherapy
- Depressed mood, anxiety
- Risk of recurrence is 50%
- Treatment includes psychotherapy and antidepressants if depression is
severe

- Increased likelihood of postpartum depression Postpartum psychosis

- Onset usually within the first month

Postpartum blues - usually in primiparous or when there is a history of perinatal


complications
- Onset within 2 weeks postpartum
- Early stages similar to postpartum blues, progress to frank psychosis
- Presents with depressed mood, irritability, mood swings, crying spells, with suspiciousness, delusions, hallucinations which may involve the child
fatigue, anxiety
- may have impulses to harm the child
- Risk factors: primiparous, premenstrual tension, premenstrual dysphoric
- agitated, poor sleep
disorder
- Treatment includes ECT, antipsychotics with mood stabilizers if bipolar
- Treatment includes support, reassurance, education
in presentation and antipsychotics with antidepressants if depressed
- Symptoms tend to remit spontaneously by the 10th day
- Advice on non-hormonal contraception

- Risk of recurrence is 70%


Postpartum depression

- Onset within first 3 months

- Similar to major depressive disorder but tend to experience more mood


fluctuation and prominent anxiety symptoms.

50
Cognitive disorders Precipitating factors

drugs (narcotics, polypharmacy),


primary neurological disease,
Delirium intercurrent illness,
surgery,
environmental (physical restraint, ICU admission, multiple
- Acute global cognitive impairment in the setting of clouded procedures)
consciousness (patient is awake but has reduced awareness of
environment and is unresponsive)

- often reversible and brief Pathophysiology

cholinergic deficiency,
dopamine (regulates acetylcholine),
Predisposing factors changes in BBB
age >65,
male,
cognitive impaired (dementia, depression), Diagnosis
function impairment (functional dependence, immobility), disturbance of consciousness with reduced ability to focus,
sensory impairment, sustain/shift attention,
decreased oral intake, change in cognition or development of perceptual disturbance,
substance use, development of disturbance over a short period of time (hours to
coexisting medical conditions days) and fluctuates

51
Types Non-pharmacological management

Delirium due to a general medical condition (evidence from avoid extremes of sensory input,
history, PE or laboratory findings) eg meningitis, head injury, relief of distress,
stroke, UTI, chest infection, PE, MI, arrhythmia, hepatic control agitation and prevent exhaustion,
encephalopathy, hyper/hypoglycemia in diabetes, epilepsy, psychosocial support
malignancy
delirium due to intoxication (symptoms developed during
substance intoxication, medication use is etiologically related to Pharmacological management
the disturbance, cognitive symptoms are in excess of intoxication
syndrome) eg insulin, digoxin, lithium, opiates, benzodiazepines ensure drug treatment for underlying physical problem is the
delirium due to substance withdrawal (symptoms developed minimum required
during or shortly after a withdrawal syndrome, cognitive antipsychotics for agitated patients with perceptual disturbances,
symptoms in excess of withdrawal syndrome), treatment of specific etiologies
delirium due to multiple etiology,
delirium not otherwise specified
Dementia

Investigations
- global impairment of intellect without impaired consciousness
Delirium Rating Scale evaluates temporal onset of symptoms,
fluctuation, perceptual disturbances and hallucinations, - cognitive functions affected include memory, orientation, perception
Confusion Assessment Method tool (requires acute onset and and attention, judgment, language and problem solving and abstract
fluctuating course with inattention and either disorganized thinking
thinking or altered level of consciousness)
- score of <23 out of 30 in MMSE is suggestive of cognitive impairment
Abbreviated Mental Test Score to establish cognitive deficits
present on admission and for a baseline score for assessing - interferes with social and occupational functioning
progress
- 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

52
Reversible causes of dementia Function

Hypothyroidism 4 instrumental activities of daily living


Vit B12 deficiency
- Ask caregiver whether pt needs assistance in these areas:
Subdural haematoma
Uremia Money management
Normal pressure hydrocephalus Medication management
Syphilis Telephone use
Traveling

Irreversible causes of dementia


Lewy body dementia
Alzheimer's disease
Vascular dementia
AIDS
- hallmarked by the presence of Lewy bodies within the brain stem and
neocortex
Questions to elicit type of memory difficulties - features of parkinsonism which fail to respond to therapy and
fluctuating cognitive loss
Being more forgetful?
Losing your train of thought? - onset of cognitive impairment should be before or within one year of
Problems trying to find the right word? extrapyramidal features
Difficulty following conversations?
- cognitive decline occurring more than one year after onset of motor
Forgetting to turn things off such as the lights or stove?
symptoms is suggestive of Parkinson's disease with dementia
Keeping track of time?
Others expressing concern about your memory?

53
Vascular dementia - criteria for Alzheimers dementia

Memory impairment
At least one of: aphasia, apraxia, agnosia, disturbance in
- comprise 25% of all dementias executive functions
- large vessel disease: multi-infarct dementia, strategic infarct dementia Impairment in occupational or social functioning
Decline from previous level of functioning
- small vessel disease: lacunar state, Binswanger disease (subcortical Not occurring exclusively during the course of delirium
arteriosclerotic encephalopathy, may have small infarcts of white matter
with sparing of cortical regions) - risk factors

- effects occur in a stepwise progression (ie memory plateaus then Age >65
worsens after a further stroke) First degree relative with Alzheimers (increases risk of early
onset Alzheimers)
- linked to a history of multiple strokes or TIAs
Head trauma with loss of consciousness and vascular damage
- remains at a fixed MMSE (Brain injury may trigger the production of -amyloid.)
Menopause (Loss of estrogen which promotes neural growth)
Less intelligence and less formal education
Alzheimer's dementia (Less synaptic connections.)
Individuals with less physical and mental activity

- Glutamate and NMDA receptor inhibitor (Memantine) or


- characterised by progressively impaired cognition and behavioural Acetylcholinesterase inhibitors (eg rivastigmine, donepezil) in mild to
change moderate Alzheimer's disease with MMSE between 10-20 and in people
with severe functional impairment in comparison to premorbid status if
- caused by a progressive neuronal damage, accumulation of -amyloid
MMSE >20
peptide, senile plaques and neurofibrillary tangles, widened ventricles

- patients show deficits of visual-spatial skill, memory, and cognitive - antipsychotic drugs for severe non-cognitive features such as psychosis
and severe challenging behaviour which is a risk to the patient and others
capabilities e.g. problem solving, word finding and speech, navigation,
arithmetic, writing or reading. - MMSE drops by 3 points every year without treatment
- diagnosis is made by excluding treatable dementias - MMSE drops 1-2 points every year with treatment

54
Mild symptoms Frontotemporal dementia
Confusion and memory loss
Disorientation
Problems with routine tasks - umbrella term for uncommon disorders primarily affecting the frontal
and temporal lobes of the brain

- typically occurs between ages 40 and 70


Moderate symptoms
- Pick's disease: gliosis, neuronal loss, neuronal Pick's bodies, personality
Difficulties with activities in daily living such as dressing, and behavioural changes with relative preservation of cognition
bathing and shopping
- Huntington's disease: subcortical dementia, psychomotor slowing,
Anxiety, aggression, agitation and suspiciousness
choreoathetotic movements, relatively intact memory/language/insight
Sleep disturbances
Wandering, pacing
Difficulty recognizing familiar people
Pseudodementia

Severe symptoms
- In depression the cognitive deficit (if present) is typically acute and
Loss of speech recent (while Alzheimer's disease is typically insidious)
Loss of appetite and weight loss
- The depressed patient will often communicate a sense of distress and
Loss of bladder and bowel control
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.

55
Wernickes encephalopathy variant form often presents with an extended neuropsychiatric
prodrome with mood disturbance or other psychiatric symptomatology.

- acute neuropsychiatric reaction to severe thiamine deficiency.


Secondary causes of dementia
- Characteristically patients are globally confused with gait ataxia and
ophthalmoplegia (nystagmus, abducens palsy or conjugate gaze disorder
are typical).
- Metabolic: thiamine deficiency, vitamin B12 deficiency, hypothyroidism,
- Thiamine deficiency may be secondary to alcoholism, vomiting during Cushing's syndrome, Wilson's disease
pregnancy, dietary insufficiency or gastric carcinoma.
- Vascular: Cerebrovascular disease, subdural haematoma
- Treatment is with urgent intravenous thiamine, but the majority will
- Neoplastic: primary CNS tumours, metastases
develop a chronic Korsakoff syndrome
- Inflammatory: SLE

- Drugs and toxins: Anticholinergics, heavy metal exposure


Creutzfeldt-Jacob disease
- Infection: Syphilis

- 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.

- Although typically occurring sporadically in middle-aged adults, a family


history may be present in 8-10%.

- variant CJD in young adults has been linked with exposure to beef
infected with the bovine spongiform encephalopathy agent. This new

56
Elderly Cognitive Assessment Questionnaire MMSE

- This is the most widely used instrument for assessing severity of the
dementia. However it can only assess the domains of cognitive deficit.
- A score of 7 or more is indicative of normal memory and a score of 4 and
The maximum score is 30. The lower the score, the more severely
below indicate probable dementia. This is useful for routine screening.
demented the patient is.

57
Geriatric Depression Scale

- 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.

58
Clock drawing test Stage 1 Normal
Stage 2 Very mild
Memory problem reported but not evident in clinical
interview.
- This is used as a measure of constructional apraxia and may also reflect
Stage 3 Mild impairment in memory, concentration and
frontal and temporoparietal functioning
occupational performance
Stage 4 Moderate impairment in memory, knowledge retrieval
and complete tasks
Stage 5 Mod to severe impairment in recent and remote
memory, frequent disorientation to time and place,
impairments of ADL
Stage 6 Severe cognitive impairment with inability to tend to ADL
without assistance
Stage 7 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.
Global Deteroration scale o Provide an environment that provides frequent cues for
- for staging of dementia orientation
o Supportive therapy & group therapy
Symptomatic treatment.
o nutritious diet, proper exercise, attention to visual and
auditory problems.
Pharmacological treatment for specific symptoms.

59
Psychotropic treatment - provides the patient with skills to approach future problems

- make sense of overwhelming problems by breaking them down into


smaller parts:
Psychoeducation
A Situation - a problem, event or difficult situation. From this can
follow:
Thoughts
- psychotherapeutic intervention
Emotions
- educate the patient and their families about the illness, the cause and Physical feelings
course of the illness and the role of medication Actions
- helps improve patient's insight, compliance, lower rate of relapse and Unhelpful Helpful
better symptom control
Thoughts: He/she ignored He/she looks a bit
- enhances support from family members me - they don't wrapped up in
like me themselves - I wonder
if there's something
wrong?
Emotional: Low, sad and Concerned for the
Cognitive Behavioural Therapy Feelings rejected other person, positive
Physical: Stomach cramps, None - feel
low energy, feel comfortable
sick
- a way of talking about how you think about yourself, the world and
Action: Go home and Get in touch to make
other people and how what you do affects your thoughts and feelings avoid them sure they're OK

- helps to change how you think ('Cognitive') and what you do - indications
('Behaviour') anxiety and panic disorders,
- focuses on the 'here and now' problems and difficulties. depression and bipolar mood disorders,
phobias (including agoraphobia and social phobia),
- Instead of focusing on the causes of your distress or symptoms in the stress disorders,
past, it looks for ways to improve your state of mind now. bulimia,
- requires commitment and cooperation from the patient obsessive compulsive disorder,
psychosis

60
Relaxation therapy Breathe in deeply.

Tense your entire body.

Deep breathing Hold the tension for few seconds, noticing how it feels.

- increases oxygen intake Then let go while exhaling, notice the difference.

- reduces tension Now tense each part of your body one by one, starting with your
feet.
- Method:
Point your toes forward then up.
Lie on your back with your feet slightly apart.
Tense your calf muscles, then relax.
Breathe in slowly through your nose. Keep the tip of your tongue
gently touching the roof of your mouth. Move on to your thighs, then your stomach muscles.

Count to 5 as you inhale. Abdomen expands. Now arch your back slightly, then press it into the floor.

Hold the breath as you count to 5 again. Continue tensing individual muscle groups.

Exhale slowly with a whoosh of sound, count of 5. Make your hands into fists, then let go.

Pause a second or two, then repeat. Press your arms against the floor, then relax them.

Increase your counts from 5 to 10 when you are more relaxed. Shrug your shoulders, then release.

Tense the muscles in your face (wrinkle your brow, clench your
teeth, open your mouth wide).
Progressive muscle relaxation
When youve finished, lie quietly for a few minutes.
- Tensing and releasing groups of muscles one at a time to relax your
entire body. Your whole body should feel at rest.
- Method:

Lie on your back.

61
ANTI-DEPRESSANT - side effects: headache, somnolence, dry mouth

TCA MAOI

- tricyclic antidepressant - monoamine oxidase inhibitor

- amitriptyline, dosulepine, clomipramine, trazodone, lofepramine, - phenelzine, tranylcypromine, isocarboxazid


imipramine - indications: depression, anxiety disorders, eating disorders, chronic pain
- indications: generalized anxiety disorder, panic disorder, nocturnal - side effects: dry mouth, postural hypotension, difficulty in micturition,
enuresis, narcolepsy, eating disorders, chronic pain confusion
- side effects: arrhythmias, sedation, dry mouth, urine retention - precaution: opioid, avoid food rich in tyramine eg cheese, liquor, liver
- contraindications: cardiac disease, patients with suicidal intention

RIMA
SSRI - reversible inhibitor of monoamine oxidase
- selective serotonin reuptake inhibitor - moclobemide
- fluoxetine, sertraline, paroxetine, citalopram, fluvoxamine - side effects: dry mouth, headache, insomnia
- indications: depression, panic disorder, social phobia, OCD

- side effects: stomach symptoms, sexual dysfunction, restlessness, Serotonin syndrome


insomnia
- Life-threatening condition due to excessive serotonin

- Triad of changes in mental status, autonomic hyperactivity and


SNRI neuromuscular abnormalities
- serotonin-noradrenaline reuptake inhibitor - Discontinue serotonergic agents, sedate with benzodiazepine
- venlafaxine - If fail give cyproheptadine

62
Azapirone

Types Effects Conclusion - buspirone

- generalized anxiety disorder


TCA & SSRI Small increased risk of Relatively safe
minor anomalies, Discontinue close to Types Effects Conclusion
prematurity EDD to avoid neonatal
withdrawal
Benzodiazepines Increased risk of Avoid if possible in
oral cleft first trimester
MAOI Teratogenic in animals AVOID

ANXIOLYTICS HYPNOTIC

Benzodiazepine Benzodiazepine - temazepam, lormetazepam, flurazepam, nitrazepam

- (short-term): alprazolam, clonazepam,

- (long-term): lorazepam, temazepam, diazepam Cyclopyrrolone - zolpidem, zopiclone, zaleplon

- indication: anxiety, panic disorder, insomnia

- Caution: effects of benzodiazepine can be potentiated by Others - Chloral hydrate, Clomethiazole edisylate
fluvoxamine/alcohol, in patients with COPD

- side effect: somnolence, risk of fall, respiratory depression, dependence,


risk of overdose due to tolerance

- Antidote: Flumazenil

63
ANTIPSYCHOTIC - Clozapine

do not initiate in patients with history of myeloproliferative


disorder or clozapine-induced agranulocytosis or
Typical (1st gen) granulocytopenia
- dopamine antagonist upon initiation of therapy, monitor WBC weekly for 6 months
followed by fortnightly for 6 months and finally monthly
- haloperidol, flupenthixol, clopenthixol, fluphenazine, chlorpromazine, discontinue treatment if WBC <2000/mm3 or ANC <1000/mm3
thioridazine, pipothiazine, trifluoperazine upon discontinuation, monitor WBC weekly for at least 4 weeks
from day of discontinuation or until WBC >3500/mm3

- side effects

akathisia (restlessness; treat with Biperiden lactate), Intramuscular injections


acute dystonia (torticollis, tongue protrusions, opisthotonos; - fluphenazine decanoate (25mg), flupenthixol decanoate (20mg),
treat with Orphenadrine), zuclopenthixol decanoate (200mg), haloperidol decanoate (5mg)(acute),
parkinsonism (rigidity, coarse tremors; treat with Benzhexol), pipothiazine palmitate, risperidone (37.5mg)
tardive dyskinesia (chewing, grimace)

Anti-parkinsonian
Atypical (2nd gen)
- biperiden, procyclidine, benzhexol, orphenadrine, benztropine
- serotonin/dopamine antagonist

- lower risk of extrapyramidal syndrome


Types Effects Conclusion
- amisulpiride, sulpiride, olanzapine, quetiapine, sertindole, ziprasidone,
risperidone, zotepine, aripriprazole, clozapine st
0.04% increased risk of Use in drug-nave
1 generation
congenital anomalies pregnant patients
- side effect: metabolic syndrome rd
Taper in 3 trimester
nd rd
Elevated rates of GDM
2 generation Taper in 3 trimester
Large-for-dates babies

64
Depot Prematurity and small- Avoid if possible - toxic syndrome
for-dates babies Continue if risk of toxic encephalopathy causing delirium
discontinuation in
cerebellar signs: Dysdiachokinesis, Ataxia, Nystagmus, Intentional
schizophrenic is highly
tremor, Slurred speech, Hypotonia
significant
treat with osmotic diuretics or haemodialysis

MOOD STABILIZER
Sodium valproate

- indications: acute mania, longer-term prophylaxis of bipolar, mixed


Carbamazepine affective states
- indications: acute mania, bipolar disorder prophylaxis - side effects: tremor, sedation, tiredness, transient hair loss
- side effects: drowsiness, ataxia, leucopenia

Lamotrigine
Lithium - indication: bipolar depression
- indications: acute mania, bipolar relapse prevention, treatment- - side effects: maculopapular rash, headache, blurred vision
resistant depression

- contraindications: renal disease, cardiac disease, pregnancy, lactation


Gabapentin
- side effects: tremor, dry mouth, nephrogenic diabetes insipidus,
hypothyroidism - indication: treatment-resistant bipolar

- becomes toxic in sodium-depleting states eg dehydration, vomiting, - side effects: somnolence, dizziness, fatigue, nystagmus
diarrhea, renal impairment

Types Effects Conclusion

65
Lithium 10% risk of Fetal echo at 16-20 weeks ECT
congenital if prescribed in first
abnormality trimester
Higher risk in later Avoid in pregnancy - electroconvulsive therapy
trimesters
- indications: severe depressive illness, catatonia, prolonged/ severe
Sodium Neural tube defects Avoid if possible in women manic episode
valproate 22% risk of impaired of childbearing age
cognition Folate 5mg/day 12 weeks - contraindications: space-occupying lesion in the brain, recent MI,
prior to conception arrhythmias, raised ICP, recent stroke,
Lamotrigine Increased risk of oral Slow reduction in dosage - side-effects: short-term retrograde amnesia, anterograde amnesia,
cleft over last month with transient post-ictal confusion, status epilepticus, headache
reinstatement after
delivery - 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.

Effective and relatively safe Preparation


PSYCHOSTIMULANTS
Both normal and high-risk Intravenous hydration
pregnancies
- caffeine, amphetamine, methylphenidate, cocaine

- indications: narcolepsy, ADHD, refractory depressive disorder (combine Careful attention to obstetric Elevation of patients right hip
with antidepressant), elderly depressed with concomitant medical illness and anaesthetic factors

Low rate of ECT-related External fetal cardiac monitoring


complications and no cases of
premature labour

66
- 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

Prescribing in pregnancy - 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
- Antipsychotic therapy should be considered mandatory in pregnant
patients with psychotic features
Breastfeeding issues
- When a planned or unplanned pregnancy occurs during antipsychotic
treatment, privilege the choice to continue the previous therapy, if - All psychotropic medication passes into breast milk at 1% of maternal
known as effective Pregnancy is not the best period to experiment the serum level
effectiveness of drugs - Reduced fetal withdrawal symptoms if psychotropes taken antenatally
- In the case of occurrence of psychotic symptoms in drug-nave pregnant - Avoid drugs or breastfeeding if baby is vulnerable
patients, privilege the drug showing the highest number of reassuring
reports and the lowest reported number of fetal anomalies (eg, - Premature
chlorpromazine) - Renal/hepatic/cardiac/neurological impairment

- Provide strict gynecological surveillance (tritest, regular clinical follow- - Close monitoring of babys behaviour
up, and ultrasound monitoring) during therapy with both first-generation - Avoid sedating medications
antipsychotics (FGAs) and second-generation antipsychotics (SGAs)
- Time feeds to avoid peak levels
- 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
Symptoms of neonatal withdrawal
during the last trimester in order to reduce the risk of neonatal
extrapyramidal reactions and seizures Match this decision with the risk of - Irritability
a relapse of psychotic symptoms - Constant crying

67
- Tremor
- Poor feeding

68
EPS and NMS Dystonia

- 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 stopping the antipsychotic or reducing the dosage
disorders 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 Parkinsonism


inability to sit still
- symptoms of bradykinesia, rigidity and resting tremors
- treat by
- treat by
stopping the antipsychotic or reducing the dosage
switching to a low EPS-producing antipsychotic stopping the antipsychotic or reducing the dosage
short term benzodiazepine or beta blockers 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

69
Neuroleptic Malignant Syndrome

- 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

70
Malaysian Psychiatry Form 5:

Order by Medical Officer/Registered Medical Practitioner to


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

Form 1:

Voluntary admission (if minor must be by guardian). Form 6:


Indefinite duration
Order by Medical Director/Head of Psychiatric Department to
detain
Valid for 1 month
Form 2:

Convert voluntary admission to involuntary detention


Valid for 1 month Form 7:

Order by 2 Medical Officers/Registered Medical Practitioners and


1 Psychiatrist to continue detention
Form 3: Valid for 3 months
Application by family to detain patient

Form 8:
Form 4: Order by Board of Visitors to detain
Recommendation by Medical officer/Registered Medical Valid for 6 months
Practitioner to detain patient
Valid for 24 hours
Form 9:

Order by Board of Visitors to continue detention


Valid for 1 year

71
Form 10:

Application by involuntary patient for discharge Restraint or seclusion

Form 11: No minor patient below the age of twelve shall be subjected to
physical means of restraint or seclusion in psychiatric hospitals.
Information to court of discharge of patient under Section 55/73
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
Form 12:
applied to patients in any psychiatric nursing home or community
Order to transfer patient from Psychiatric Hospital to another mental health centre, except during an emergency and the
Psychiatric Hospital by Director General/Authorized Person patient shall then be transferred to psychiatric hospitals without
delay.
If the period of physical means of restraint of a patient exceeds
Patients Rights 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
1. The reasons of his admission and detention and means of hours consecutively or for more than twelve hours intermittently
discharge, leave or transfer over a period of forty eight hours, without an independent review
2. Treatment, information, confidentiality, personal identity, privacy by a psychiatrist.
3. Adequate accommodation
4. Recreational activities
5. Practice gender identity Restraint area
6. Practice religious belief of their choice There shall be a designated restricted area with a dedicated
7. Communicate with persons outside observation bay manned by a qualified, trained and experienced
8. Receive visitors staff for the purpose of monitoring of patients.
9. Have access to a second psychiatric opinion
The area shall be adequately lit and ventilated.
10. Obtain legal representation and appeal to the Board of Visitors or
the Director General for discharge

72
Physical restraint
Equipment that may be used as physical means of restraint

Indications for physical means of restraint Restraint bed;


Restraint chair;
A restraint is for the purpose of the medical treatment of the Padded restraints made of either calico cloth or cotton , leather ,
patient. nylon, vinyl , polyurethane, silicone or rubber based materials;
To prevent the patient from causing injury to himself or any other and
person. Any other equipment approved by the Director General.
To prevent the patient from persistently destroying property.
When other less restrictive method of treatment to calm the
patient has not been successful. Application of physical means of restraint

carried out or supervised by qualified, trained and experienced


Equipment prohibited to be used as physical means of restraint personnel
applied only to the limbs of a patient.
Strings, ropes and raffia; It shall not be necessary to obtain a persons consent to the
Handcuffs, shackles application of physical means of restraint.
Body restraint; No physical restraint is allowed in the psychiatric nursing home
Strait jacket; and community mental health centre, EXCEPT at the time of
Chains (from whatever material); Transportation of patients to a psychiatric hospital.
Wire; If the patient is acutely disturbed, a member of the nursing staff
Bandage; shall visit at intervals of not more than fifteen minutes.
Equipment with tears, protruding metal parts or any defect that A medical officer or registered medical practitioner shall examine
may endanger patient. the acutely disturbed patient at intervals of not more than four
hours.

73
Seclusion
Removal of physical means of restraint

Decision to remove the restraints shall be made by the psychiatric Indications for seclusion
nurse on-duty.
The medical officer or registered medical practitioner must be A patient in a psychiatric hospital may be kept in seclusion only if
informed of the termination of restraints. 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
Chemical restraint
has not been successful.

Application of chemical means of restraint


Application of seclusion
Consent for chemical means of restraint consent shall be
It is not necessary to obtain a persons consent for his seclusion
obtained from a voluntary patient prior to chemical means of
to him or her.
restraint.
A member of the nursing staff shall visit an acutely disturbed
If the patient is acutely disturbed, a member of the nursing staff
patient at intervals of not more than fifteen minutes.
shall visit at 15 minutes interval.
A medical officer or registered medical practitioner shall visit the
A medical officer or registered medical practitioner shall
patient under seclusion at intervals of not more than four hours.
examine the acutely disturbed patient at intervals of not more
The patient may request to communicate with others while
than 4 hours.
under the seclusion.

74

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